The 

Community  Health 

Problem 

(1920) 


m 


Athel  Campbell  Burnham 


RA 
425 
.B8 
1920 


The  Gormnunity  Health 
Problem 


By 
ATHEL  CAMPBELL  BTJENHAM,  M.D. 

HEALTH  SEBVIOE^  ATLANTIO  DIVIBIOV,  AIOSIOAN  RSD  OSOSS; 

ATTENDING  8UBOE0N,  VOLUNTBEB  HOSPITAL,   NEW  YOBK 

city;    LIEUTENANT    COLONEL,    MEDICAL    RESEBVE 

C0BF8,  u.  s.  abict;  fellow  new  YOBX 

AGADEHY  OP  MEDICINE 


Nfto  fork 

THE  MACMILLAN  COMPANY 

1920 


St 


Copyriaht,  1030 

btthe  macmillan  company 

flat  op  and  eleetiotyped.    Publiahed  Octobar.lOSO 


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THE 
COMMUNITY  HEALTH  PROBLEM 


r 


PBEFACE 

The  various  requests  the  writer  has  received  for  references 
to  health  literature  dealing  with  what  has  come  to  be  known 
as  the  community  health  movement,  have  indicated  the  desir- 
ability of  a  brief  treatise  upon  the  community  health  problem 
in  its  relation  to  the  modem  conception  of  social  medicine. 

The  welfare  worker  who  is  called  upon  to  meet,  from  & 
practical  standpoint,  health  conditions  as  she  finds  them  either 
in  the  crowded  tenement  districts  of  the  larger  cities  or 
scattered  over  a  large  territory  in  a  rural  commimity,  often 
fails  to  accomplish  maximum  results  because  of  a  hazy  and 
fragmentary  understanding  of  the  health  problem  and  very 
indefinite  ideas  as  to  its  solution.  Public  health  nurses  and 
practising  physicians,  who  because  of  routine  duties  have  been 
unable  to  follow  the  recent  health  literature,  are  sometimes 
handicapped  in  their  work  because  of  a  lack  of  understand- 
ing of  the  modem  movement  toward  the  socialization  of  medi- 
cine. For  such,  and  for  all  others  interested  in  the  improve- 
ment of  health  conditions  as  part  of  a  community  welfare 
movement,  this  work  is  intended. 

The  attempt  has  been  made  briefly  to  outline  the  health 
problem  as  it  exists,  and  to  indicate  the  most  important  of 
the  measures  which  are  being  suggested  for  its  solution,  in 
order  to  permit  the  reader  to  secure  in  one  small  volume  a 
fairly  comprehensive  understanding  of  social  medicine  in  its 
relation  to  community  health. 
New  York  City. 


TABLE  OF  CONTENTS 

Pbefaob 

CHAPTER  I 
The  Health  of  the  Community 3 

CHAPTER  II 
SioKifEss  AS  A  Cause  or  Poveety 15 

CHAPTER  III 
The  Pbivate  Phtsioian  and  Communitt  Health.  . .    23 

CHAPTER  IV 
Health  Defabtments  and  Community  Health.  ...     30 

CHAPTER  V 
The  Public  Health  Nubse 38 

CHAPTER  VI 
The  Campaiqr  roB  Betteb  Health  54 

CHAPTER  Vn 
Wobejcen's  Compensation  Insubanoe   67 

CHAPTER  VIII 
CoMPuisoBY  Health  Insueance  75 

CHAPTER  IX 
Industbial  Medicine  84 

CHAPTER  X 
State  Medioinb   92 

CHAPTER  XI 
Health  Centebs  99 

CHAPTER  XII 
The  Social  Unit  Expebiment 108 


CHAPTER  XIII 

TUBKSCULOSIS     115 

CHAPTEH  XIV 
Social  Htgienb  ik  its  Relation"  to   CoMMUNirr 
Health   122 

CHAPTER  XV 
Rehabilitation  op  the  Disabled  128 

CHAPTER  XVI 
Endowed  Health  Dbmonstbations  139 

Refeeekoss  to  Reoekt  Publioatioh^s  150 


THE  COMMUNITY  HEALTH  PROBLEM 

CHAPTER  I 

THE  HEALTH  OF  THE  COMMUNITY 

The  public  health  problem  of  today  ia  a  commtmity  prob- 
lem. It  is  no  longer  possible  to  separate  the  health  of  the 
individnal  from  the  health  of  the  community  at  large.  Con- 
ditions of  work,  play,  education,  food  supplies  and  trans- 
portation, which  were  at  one  time  largely  the  personal  con- 
cern of  the  individual  have  today  become  community  prob- 
lems and  must  be  solved  as  such.  The  health  of  the  individual, 
influenced  largely  by  man's  environment,  presents  a  similar 
problem. 

THE  BESPOXSIBIUTY  FOB  SICKNESS 

Besponfiibility  for  accident  and  disease  is  no  longer  con- 
sidered merely  as  a  personal  problem,  it  is  a  community 
problem  as  welL  Just  as  we  insist  that  every  American  shall 
have  the  benefits  of  public  education  so  should  we  insist  upon 
the  inherent  right  of  every  American  to  the  possession  of  a 
body  free  from  the  handicap  of  preventable  disease. 

The  causes  of  disease  are  found  in  individual,  industrial 
and  community  conditions,  many  of  which  are  under  public 
supervision.  These  conditions  must  be  studied  and  corrected 
by  the  community  before  any  appreciable  decrease  in  pre- 
ventable disease  can  be  attained.  For  example,  in  order  to 
protect  the  growing  child  from  infection  with  bovine  tuber- 
culosis the  state  health  authorities  may  inspect  and  condemn 
infected  cattl€  hundreds  of  miles  away— -cows  which  neither 
the  child,  nor  hii  parents,  nor  even  Ids  physician  have  ever 
seen.  The  commonity  recognizes  its  responsibility  in  the  case 

3 


4         THE  COMMUNITY  HEALTH  PROBLEM 

of  bovine  tuberculosis  but  in  the  case  of  human  iuberculoeis 
the  responsibility  is  less  clearly  defined.  Some  communities 
make  fairly  adequate  provision  for  the  care  of  the  tuber- 
culous, others  undertake  the  care  of  charity  cases  only  and 
some  make  little  or  no  provision  for  the  treatment  of  patients 
suffering  from  this  disease. 

Until  comparatively  recently  the  problem  of  public  health 
has  been  almost  entirely  one  of  prevention  in  the  case  of 
acute  infectious  disease.  SmaU-pox,  typhus  and  plague  have 
been  all  but  completely  wiped  out  Scarlet  fever  and  diph- 
theria have  been  greatly  diminished.  During  the  last  few 
years  there  has  been  a  praiseworthy  stimulation  of  interest  in 
the  prevention  of  disease,  with  a  consequent  steady  progres- 
sion toward  better  health.  The  movement  at  present  ia,  not- 
withstanding the  rapid  progress  already  made  or,  possibly 
because  of  the  very  rapid  growth  of  the  movement,  somewhat 
inco-ordinate  and  characterized  by  a  certain  amount  of  dup- 
lication of  effort  and  waste  of  energy  which  is,  from  the 
nature  of  things,  unavoidable  during  the  early  stage  of  a 
movement  of  this  sort. 

DISABILITY   DI8C0VEBED   BT   THE  DRAFT 

Examination  of  the  records  of  nearly  five  million  drafted 
men  has  focused  attention  upon  the  fact  that  there  is  in 
the  United  States  a  health  problem  which  has  been  gen- 
erally disregarded.  Not  entirely  so,  because  during  recent 
years  many  exhaustive  health  surveys  have  brought  to  light 
a  tremendous  amount  of  untreated  illness,  but  such  statistics 
have  been  read  by  comparatively  few  and  have  not  made  the 
same  impression  upon  the  popular  imagination  as  have  the 
more  striking  figures  which  resulted  from  the  draft  board 
examinations. 

There  is  in  every  community,  if  we  accept  the  figures  o£ 
the  Surgeon-General,  a  comparatively  large  amount  of  pre- 
ventable disease  among  young  men  between  the  ages  of  18 
and  31.  The  figures  vary  somewhat  in  different  parts  of  the 


THE  HEALTH  OP  THE  COMMUNITY  5 

country  and  there  is  a  variation  between  the  urban  and  rural 
population,  but  the  figures  taken  as  a  whole  represent  an 
approximately  accurate  cross  section  of  the  country. 

The  following  figures  furnished  by  the  Surgeon-General* 
of  the  TJ.  S.  Army,  indicate  the  percentage  of  disability 
found  in  the  examination  of  approximately  6,000,000  drafted 
men: 

801CE  niFOBTANT  DEFECTS  BEVSALED  BY  THE  DBAFT 

Percent, 

1.  Defects  of  feet  (flat-foot  11  per  cent) 13. 

2.  Venereal  disease — 

During  first  period  of  draft 2.9 

In  later  period  of  draft 6.7 

3.  Hernia  and  enlarged  inguinal  rings 4. 

4.  Defective  vision  (largely  errors  of  refraction) . .  3.5 
6.    Defective  physical  development,  including  under- 
weight and  under-height 3.5 

6.  Organic  diseases  of  the  heart 3. 

7.  Deformities  or  loss  of  extremities 3. 

8.  Tuberculosis   2.5 

9.  Hypertrophy  of  tonsils 2.33 

10.  Defective  and  deficient  teeth 1.33 

11.  Mental  deficiency 1.25 

12.  Otitis  media  (purulent)  1. 

13.  Hemorrhoids,  varicocele,  varicose  veins 1. 

14.  Goitre  (simple  and  exophthalmic)  0.75 

16.  Deformities  of  the  hand 0.75 

16.  Cardiac  arrythmias  and  tachycardia 0.50 

17.  Asthma  0.25 

According  to  figures  obtained  from  various  sources  the 
number  of  men  disqualified  for  military  service  was  found 
to  vary  between  21  and  34  per  cent.,  depending  upon  the 

*Ir«Iand,  Mcnltts  W.;  Physical  ft  Hygienic  Benefits  of  MlUtary  Train- 
ing MM  Demonstrated  by  the  Wax-  Journal  A.  M.  A..  VoL  74;  Mo.  JB, 
Feb.  21.  WO. 


6  THE  COMMUNITY  HEALTH  PBOBLEM 

statistics  qaoted.  The  records  of  the  Surgeon-General  show 
that  29  per  cent,  had  some  form  of  disability.  Other  records 
show  a  sli^tly  higher  figure.  SufBce  it  to  saj  that  approxi- 
mately one-third  of  the  young  men  of  the  country  were  phy- 
sically unable  to  perform  full  military  duty.  Li  the  later 
examinations  14.5  per  cent,  were  rejected  by  local  boards  as 
unfit  for  serrice  and  about  7  per  cent,  were  rejected  by  military 
boards  after  having  been  sent  to  camp.  Only  fiftf-three  per 
cent,  were  accepted  aa  fully  meeting  the  military  standard 
with  no  defects  recorded. 

If  preventable  iUness  (and  physical  disability  which  results 
from  preventable  iUness)  is  found  to  such  a  great  extent 
among  young  men  during  a  period  when  the  highest  d^ee 
of  physical  development  is  expected,  is  it  not  natural  to  sup- 
pose that  preventable  illness  exists  in  a  proportionate  amount 
in  other  members  of  the  community? 

This  number  errs  on  the  side  of  conservatism  for  in  the 
haste  of  mobilization  many  minor  disabilities  were  overlooked 
and  many  men  were  taken  into  the  Army  as  ''physically  fit" 
only  to  be  found  disqualified  at  a  later  date.  It  is  safe  to  say 
that  over  one-half  of  the  young  men  of  military  age  show 
some  form  of  physical  defect.* 


SICKNS3S   HUitVlYB 

So  much  for  the  military.  Without  attempting  to  determine 
whether  adequate  treatment  had  been  available  for  the  aver- 
age drafted  man  and  whether  such  treatment  might  have 
modified  the  findings,  let  us  examine  the  status  of  the  civilian 
population.  In  general,  no  such  complete  figures  are  avail- 
able for  civilians,  but  in  recent  years  a  number  of  health 
surveys  have  been  carried  out  in  various  parts  of  the  country 
with  most  striking  results,  which  indicated  that  general  condi- 
tions were  at  least  as  bad  as  those  discovered  in  the  draft. 

*A  r«port  published  In  the  Journal  of  tho  American  Modical  AaaoclatioB 
(April  10,  1K20).  states  that  according  to  recent  figures  onlj  25  per  cent, 
of  the  drafted  men  were  qualified  according  to  pre-war  atandarda. 


THE  HEALTH  OP  THE  COMMUNITY     7 

Just  what  is  a  health  suryey  and  how  is  it  carried  out  ? 
As  ordinarily  understood  a  health  survey  is  the  examination  of 
the  health  conditions  in  a  given  community  especially  with 
reference  to  disability  due  to  injury  and  disease.  In  some 
cases  only  meagre  details  are  furnished  and  include  only  a 
report  of  those  seriously  ill  and  unable  to  work.  In  other  sur- 
veys every  member  of  the  community  is  carefully  examined 
and  a  notation  made  of  non-disabling  conditions  such  as 
defective  teeth,  adenoids,  varicose  veins,  and  other  similar 
conditions.  As  a  consequence  of  the  varying  conditions  under 
which  health  surveys  are  carried  out,  it  is  very  difficult  to 
compare  figures  given  in  different  surveys  without  clearly 
understanding  the  methods  adopted  by  the  examiners. 

Surveys  are  made  difficult  because  of  the  fact  that  most 
adults  object  to  a  physical  examination  by  a  physician  unless 
they  are  seriously  ill.  There  are  those  who  resent  what  they 
consider  to  be  an  intrusion  into  their  private  affairs  and 
others  who,  while  not  actively  antagonistic,  show  little  incli- 
nation to  supply  information  required  to  complete  the  survey. 

For  this  reason,  and  others  which  are  self  evident,  it  has 
been  much  easier  to  make  a  health  survey  among  children  of 
school  age  than  among  either  infants  or  adults.  Consequently 
we  are  much  better  informed  as  regards  the  health  conditions 
of  children  of  school  age  than  of  other  members  of  society. 
After  making  due  allowance  for  those  children  who  are  crip- 
pled or  too  ill  to  attend  school,  the  results  of  so-called  "school 
ezamixtations"  offer  reasonably  accurate  figures  upon  which 
to  baae  an  estimate  of  the  general  health  of  the  community. 

EZAHIKATIONS  OF  SCHOOL  OHILDBEN 

Pop  some  years  New  York  State  has  had  a  fairly  compre- 
hensive law  requiring  the  examination  of  school  children. 
During  the  year  1918  over  700,000  school  children  were 
examined  and  over  500,000  were  found  to  have  physical  de- 
fects. In  New  York  City  defects  were  found  in  77  per  cent. 
of  the  children  examined.     In  rural  districts  and  villages 


8 


THE  COMMUNITY  HEALTH  PBOBLEM 


the  percentages  were  somewhat  lower.  The  New  York  State 
Reconstruction  Commission,  in  discussing  these  findings,  sug- 
gests that  the  smaller  percentages  in  rural  communities  are 
due  to  "the  varying  degree  of  thoroughness  in  examinations." 

PHYSICAL  CONDITION  OF  SCHOOL  CHILDSEN  1918 
720,176  Children  Examined  in  N.  Y.  State 


Defects 


New  York 

Cit 
Numl 


Dcr 


Cities  and 
Villases 
Number 


Rural 
Schoob 
Number 


Vision 

Hearing 

Teeth 

Enlarged  or  Diseased  Tonsils. . 

Breathing 

Nutrition 

Lungs 

Total  Number  of  Defective 
Children 


23,362 

16,692 

1,214 

2,511 

161,686 

63,926 

33.476 

29,766 

25,168 

10,203 

35,225 

4,678 

742 

642 

18,691 

4,699 

70,561 

42,202 

17,455 

3,859 

834 


190,898 
(77%) 


138,093 
(67%) 


177,063 
(63%) 


During  recent  years  the  Bureau  of  Child  Hygiene  of  New 
York  City  has  made  a  careful  study  of  the  subject  of  mal- 
nutrition in  school  children.*  Ignorance  of  the  nutritive  value 
of  foods,  th^  high  cost  of  food,  carelessness  in  its  preparation, 
and  the  use  of  food  substitutes  all  play  a  part  in  the  causation 
of  mal-nutrition.  Many  cases  were  found  to  be  secondary  to 
physical  defects  such  as  enlarged  tonsils,  defective  teeth,  etc. 
In  a  nutritive  survey  of  school  children  an  arbitrary  stand- 
ard, known  as  the  Dumferline  Scale,  has  been  adopted  for 
convenience  of  classification.  This  consists  of  four  classes 
as  follows : 

Excellent — the  child  is  well  nouriBhed. 
Good — ^nutrition  falls  short  of  excellent. 
The  child  requires  supervision — borderline. 
Nutrition  seriously  impaired — requires  medical 


Class  1. 
Class  2. 
Class  3. 
Ci&ss  4. 
treatment 

•Report  of  lb*  Public  Bealth  Committas  on  Rceonttroetton. 
Xork  Itata.  Oct.  24.  1010. 


Vmr 


THE  HEALTH  OP  THE  COMMUNITY     9 

During  1918  neaxly  200,000  school  children  were  examined 
and  graded  for  nutrition  with  the  following  result: 

EXAMINATION  OP  SCHOOL  CHILDEEN,  1918 

City  of  New  York 

Public  Parochial 

Schools  Schools  Total 

Claas  1 35,606  5,372  40,978 

Class  2 92,588  15,702  108,290 

Class  3 25,346  3,908  29,254 

Class  4 6,205  647  6,852 

Totals 158,745  25,629  184,374 

It  is  estimated  that  the  number  of  children  in  Class  4  has 
increased  during  1919,  since  the  cost  of  milk  and  butter  has 
risen  so  high  that  many  families  have  economized  by  cut- 
ting down  on  the  daily  supply,  substituting  other  less  nutri- 
tious foods. 

Of  the  children  requiring  medical  treatment  probably  only 
a  comparatively  small  number  actually  are  receiving  medical 
attention.  Some  are  under  the  care  of  private  physicians  and 
others  are  being  treated  by  welfare  associations  and  dispen- 
saries, but  a  large  number  are  neglected  and  will  continue  to 
be  neglected  unless  treatment  is  insisted  upon  by  school 
authorities  or  by  welfare  organizations. 

OOIOIUNITT  HEALTH  SUBTETS 

"Among  adults  there  are  few  surveys  which  indicate 
physical  disability  with  the  same  amount  of  detail  as  is 
found  in  the  draft  board  and  school  reports.  As  has  been 
noted,  adults  are  apt  to  object  to  physical  examination  and 
consequently  most  of  the  surveys  include  only  personal  state- 
ments as  to  actual  disability. 

In  six  surveys  made  by  the  Metropolitan  Life  Insurance 
Company  covering  a  total  of  637,000  persons  holding  policies. 


10        THE  COMMUNITY  HEALTH  PBOBLEM 

it  was  found  that  there  were  12,114,  or  1.9  per  cent.,  who  were 
Buffering  from  an  illness  severe  enough  to  prevent  them  from 
going  to  work.  In  addition  to  this  number  about  1200  were 
sick  but  were  still  able  to  work.  No  attempt  was  made  to 
discover  those  suffering  from  light  illness  and  non-incapaci- 
tating disability.  In  tibe  Chelsea  survey  the  figures  were  1.5 
per  cent,  sick,  and  1.4  per  cent,  disabled.  In  North  Carolina 
the  figures  were  2.85  per  cent  sick,  and  2.3  per  cent  disabled. 

Information  as  to  adult  sick  rates  may  be  secured  in  another 
way,  that  is,  by  considering  the  number  of  days  sick  per  year 
for  each  member  as  shown  by  the  records  of  sickness  and 
death  benefit  societies.  Such  records  compiled  by  the  Bureaxi 
of  Labor  Statistics  show  that,  for  all  ages,  there  was  a  disa- 
bili^  rate  (per  insured  person)  of  6.6  days  per  year.  This 
figure  is  approximately  5  days  per  year  for  insured  persons 
under  35  years  of  age  and  gradually  increases  to  15  days  per 
year  for  members  70  and  over. 

In  time  of  epidemic  the  amount  of  sickness  may  be  greatly 
increased.  During  the  epidemic  of  influenza  in  1918  it  was 
shown  that  in  a  total  of  148,245  persons  canvassed*  in  various 
parts  of  the  United  States,  43,580  suffered  from  an  attack  of 
influenza.  This  is  a  case  rate  of  29.4  per  cent 

FSAHINQHAM  HEALTH  DElCONSTfiATION 

In  the  iBVamingham  Communis  Health  and  Tuberculosis 
Demonstration  a  careful  health  survey  was  made  of  the  entire 
conmixmity.**  Every  individual  who  would  permit  examina- 
tion was  systematically  examined  by  a  physician  trained  in 
this  work.  In  all,  4,473  persons  were  examined  during  a 
period  of  several  days. 

.  Minor  ailments  such  as  colds  and  defective  teeth  were 
included  with  the  result  that  3,466  or  77  per  cent,  were  found 
to  show  physical  disability  of  some  sort.    This  is  an  enormous 

•AnntiAl  Report  U.  8.  Pabllc  Health  Serrlce,  Wtsblnffton.  1919. 
**  Annstrong,  Donald  6.:  Pramlngham  Monograph  No.  4;  Commimltr 
BMlth  Station,  Framinghaia,  Hub.,  Novembor,  191& 


THE  HEALTH  OF  THE  COMMUNITY  11 

figure,  and,  as  might  be  expected,  represents  largely  ^'minor 

ills."  These  may  be  classified  as  follows:  I 

KIKOB  ILLS  IN  EZAIOKATION  OF  4,473  PEB80KS  ' 

Defective   teeth    1,006 

Enlarged  tonsils    563  | 

Colds,  coryza,  etc 132  i 

Bronchial  pulmonary  affection   (undiagnosed)  265 

Glandular  system 277 

Miscellaneous  100 


2,443 


Of  the  major  ills  there  was  a  total  number  of  1,113  of 
which  96  were  pulmonary  tuberculosis.  The  number  seriously 
ill  represented  25  per  cent,  of  the  total  examined. 

The  result  of  these  examinations  shows  the  large  amount  of 
illness  usually  disregarded.  In  this  same  group  a  census  taken 
before  the  examinations  showed  only  6.2  per  cent,  who  reported 
any  illness.  Compare  this  number  with  77  per  cent  as  found 
by  the  medical  examinations  or  even  with  25  per  cent,  which 
represented  those  having  "major  ills.*' 

Of  the  total  number  of  affections  found,  both  minor  and 
serious.  Doctor  Armstrong  estimates  that  61  per  cent  ar« 
eiAer  "theoretically  preventable  or  easily  remediable,*'  while 
about  15  per  cent  are  non-preventable.  The  balance  are 
classed  as  "doubtfully  preventable." 

HEALTH  IK  THB  ABHT 

If  we  turn  now  to  the  report  of  the  Surgeon-General,  XT.  S. 
Army,  for  1918,  we  find  that  among  picked  men  (remember 
a  large  number  were  not  accepted  for  the  Army  because  of 
physical  disabilities)  there  is  always  a  fairly  constant  sick 
rate.  This  is  called  the  non-effective  rate,  meaning  thereby 
that  among  a  given  number  of  men  a  certain  number  per  hun- 
dred are  **non-€ffective"  or  unfit  for  duty.  The  non-effectira 


12        THE  COMMUNITY  HEALTH  PEOBLEM 

rate  for  1917  among  enlisted  men  was  22.21  per  1,000  in  the 
United  States.  In  Europe  it  was  slightly  less  and  in  the 
Philippines  considerably  more.  Over  a  series  of  years  the 
Army  non-effective  rate  runs  pretty  regularly  between  2  and 
3  per  cent.  There  are  several  factors  which  tend  to  make  the 
rate  lower  in  the  Army  than  in  civilian  life,  chief  of  which  is 
the  fact  that  soldiers  are  carefully  picked  young  men  pre- 
sumably able  to  do  full  duly  when  enlisted.  In  addition,  when 
soldiers  develop  chronic  diseases  they  are  discharged  so  that 
such  diseases  as  tuberculosis  and  chronic  nephritis  play  a  com- 
paratively small  part  in  the  non-effective  rates. 

THB  SICK  IS  TEZ  COMHUHITT 

If  the  figures  already  given  are  carefully  considered  it  will 
be  seen  that  while  there  is  abundant  evidence  of  illness  in  a 
given  community,  it  is  rather  difficult  to  state  exactly  any 
figure  which  would  fairly  represent  the  total  number  requiring 
treatment  at  any  one  time,  but  by  a  consideration  of  the  facts 
we  may  judge  rather  closely  the  number  seriously  iU. 

If  we  start,  for  example,  with  a  consideration  of  those  who  \ 
are  too  ill  to  work  we  will  find  that,  excluding  the  number 
who  have  a  permanent  disability  imsuitable  for  treatment — 
such  as  an  amputated  leg  or  deformed  hand — there  is  a  fairly 
definitely  fixed  percentage  which  represents  those  incapaci- 
tated. This  figure  is  as  a  rule  between  2  and  3  per  cent 
At  times  it  may  drop  below  this  figure  and  during  epidemics 
it  may  rise  as  high  as  eight  or  ten  per  cent,  or  even  higher. 

Of  this  2  per  cent,  probably  at  least  one-half  should  be 
under  hospital  treatment  so  tliat  in.  any  given  coiomunity 
there  should  be  at  least  one  hospital  bed  for  every  hundred 
persons.  As  a  matter  of  fact  this  number  is  very  conservative, 
it  being  claimed  by  many  that  two  hospital  beds  for  every 
hundred  persons  is  the  least  number  consistent  with  adequate 
treatment  In  military  camps  where  there  are  no  accommo- 
dations for  '*home  treatment"  this  number  should  be  increased 
to  at  least  5  per  cent  in  time  of  peace  and  considerably  more 
during  war. 


THE  HEALTH  OF  THE  COMMUNITY  13 

In  addition  to  those  unable  to  work  because  of  illness  there 
is  a  certain  percentage  who  feel  the  effects  of  illness  but  con- 
tinue to  work  (among  these  are  cases  of  chronic  heart  disease, 
tuberculosis,  kidney  disease,  chronic  bronchitis  and  many 
minor  ailments).  This  is  usually  estimated  as  about  2  to 
4  per  cent.,  so  that  the  figure  for  the  total  acknowledged 
illness  will  usually  average  pretty  close  to  6  per  cent.*  That 
is  to  say,  that  if  one  physician  should  undertake  the  care 
of  a  typical  community  of  a  thousand  persons  he  would  have 
about  60  patients  at  all  times.  This  does  not  mean  that  such 
a  physician  would  see  60  patients  a  day.  Many  would  be  at 
work,  reporting  for  treatment  weekly  or  monthly,  or  possibly 
even  less  frequently. 

If  we  accept  the  figure  of  6  per  cent,  as  representing  the 
munber  in  a  community  who  admit  illness  and  acknowledge 
the  necessity  for  treatment,  we  still  have  a  considerable  dis- 
crepancy between  this  figure  and  the  figures  obtained  from  the 
draft  boards,  school  surveys  and  the  Framingham  survey 
quoted  above.  Part  of  the  discrepancy  is  due  to  those  who 
suffer  from  a  permanent  disability  such  as  a  deformed  hand  or 
amputated  finger  and  do  not  consider  that  they  are  ill;  part 
is  due  to  the  ignorance  of  the  symptoms  of  disease ;  and  a  large 
part  is  due  to  minor  ills  which  for  economic  reasozis  have  been 
nntreated  and  are  consequently  disregarded. 

However  the  exact  percentage  of  sickness  in  a  given  locality 
is  of  less  importance  than  is  the  fact  that,  in  each  and  every 
conmranity,  there  are  constantly  found  some  persons  seriously 
sick,  some  ill  but  not  incapacitated,  and  a  large  number  of 
others  suffering  from  minor  iDs  of  more  or  less  consequence. 
The  eflBciency  of  the  methods  adopted  in  dealing  with  these 
conditions  has  a  direct,  influence  on  the  social  and  economic 
life  of  the  community. 

Every  community  should  examine  closely  into  the  prepara- 
tion it  makes  for  care  of  its  citizens'  health.  Do  the  sick 
receive  adequate  treatment?  Are  there  sufficient  hospital  beds? 

*In  Dr.  ArmBtrong'a  health  eennis  the  nnmber  who  said  they  war* 
sick  represented  6.6  per  cent,  of  the  total  sorreyed. 


14        THE  COMMUNITY  HEALTH  PROBLEM 

Are  proper  measures  being  taken  to  educate  the  mother  in 
the  care  of  her  child  and  is  every  effort  being  made  to  decrease 
preventable  disease  and  to  diminish  remedkble  ills? 

It  is  not  enough  to  increase  wages  and  to  expect  the  indi- 
vidual to  secure  medical  treatment.  Every  patient  suffering 
from  an  infectious  disease  is  a  menace  to  his  neighbors,  and 
every  case  of  disability  is  an  economic  drain  on  the  community 
as  a  whole.  Education  of  the  medical  profession  has  decreased 
illness  but  not  sufficiently  to  wipe  out  certain  easily  pre- 
ventable diseases;  public  education  has  not,  up  to  the  present, 
sufficiently  influenced  physical  health 

Neither  increased  wealth  nor  advances  in  medical  science 
will  develop  the  full  r^ources  of  the  youth  of  the  nation 
unless  directed  by  a  well-planned  concerted  effort  to  apply 
the  lessons  taught  by  medical  science  to  the  eveiy-day  prob- 
lems of  public  health. 


CHAPTEE  II 
SICKNESS  AS  A  CAUSE  OF  POVERTY 

In  the  struggle  between  capital  and  labor  the  pecnniarj 
rewards  of  the  workman  have  steadily  increased,  and  this  was 
true  even  before  the  World  War  upset  all  pre-war  standards. 
The  recent  rapid  increase  of  wages  combined  with  a  diminished 
supply  of  labor  has  tended  to  decrease  the  ordinary  evidences 
of  poverty.  Bread-lines  are  strikingly  short;  municipal  lodg- 
ing houses  have  few  guests;  and  unemployment  is  at  the 
TniTiiTriTiTTi  rate  for  many  years. 

There  is,  however,  still  considerable  poverty  due  to  disease. 
The  increased  income  has  not,  as  might  be  expected,  been 
hoarded  against  the  proverbial  rainy  day  but  has  been 
expended  for  luxuries  of  a  temporary  character.  The  workman 
receiving  an  unprecedented  high  wage  is  living  better  than 
ever  before.  More  automobiles,  more  phonographs,  and  more 
fine  clothes  have  been  purchased  by  wage  earners  than  ever 
before.  Moving  picture  theatres  are  flourishing,  candy  and 
soda-water  is  sold  in  enormous  quantities,  and  silk  has  become 
the  daily  raiment  of  the  skilled  worker.  This  is  perhaps  as  it 
should  be.  Certainly  labor  has  waited  a  long  time  for  the 
coming  of  the  day  of  high  wages  and  is  entitled  to  a  few  of 
the  luxuries  of  life,  but  it  is  certain  that  the  average  wage 
earner  is  not  saving  any  considerable  portion  of  his  wage  as 
an  insurance  against  loss  due  to  illness.  There  is  today,  in 
every  large  city,  an  enormous  number  of  persons  entirely 
dependent  upon  charity  as  a  direct  result  of  sickness  and  there 
will  be  more  when  the  present  boom  begins  to  diminish,  and 
still  more  when  really  hard  times  arrive. 

Prosperity  during  and  after  the  war  tended  in  one  way 
to  decrease  poverty  due  to  physical  disability.    In  every  com* 

15 


16        THE  COMMUNITY  HEALTH  PBOBLEM 

mtmity  there  is  always  a  certain  number  of  crippled  and 
subnormal  individuals  who  are  unable  to  secure  any  sort  of 
remunerative  employment  during  periods  when  supply  of 
labor  exceeds  the  demand.  In  the  prosperity  which  followed 
the  World  War  most  of  these  individuals  secured  employment 
at  a  Uving  wage.  Others,  however,  who  are  actually  too  ill  to 
work  are  less  fortunate.  The  increased  cost  of  living  and  the 
diminished  purchasing  power  of  the  dollar  makes  their  plight 
doubly  difficult  and  throws  an  increased  burden  upon  the 
resources  of  charity.  When  sickness  occurs  it  is  found  that 
the  cost  of  medicine  has  increased,  medical  attention  is  con* 
siderably  more  expensive  than  during  the  pre-war  period  and 
rents  and  household  expenses  have  more  than  doubled. 

So  that  we  find  that,  even  with  high  wages,  illness  of  the 
bread-winner  of  the  family,  for  an  extended  period,  often 
results  in  economic  distress.  This  is  true  in  the  case  of  the 
wage  earner  so  frequently  as  to  be  considered  the  rule.  Those 
who  are  especially  wasteful  are  almost  immediately  plunged 
into  poverty;  those  who  have  greater  means  do  not  feel  the 
pinch  of  want  until  later ;  while  a  few  of  the  more  provident 
may  pass  through  a  fairly  long  illness  without  actual  distress. 

Edward  T.  Devine  of  the  Charity  Organization  Society  of 
New  York  City  says  in  his  book  **Misery  and  its  Causes": 
''HI  health  is  perhaps  the  most  constant  of  the  attendants  of 
poverty.  It  has  been  customary  to  say  that  25  per  cent,  of 
tiie  distress  known  to  charitable  societies  is  due  to  sickness. 
An  inquiry  into  the  physical  condition  of  the  members  of  the 
families  that  ask  for  aid,  without  taking  any  other  complica- 
tion into  account,  clearly  indicates  that  whether  it  be  the  first 
cause  or  merely  a  complication  from  the  effect  of  other  causesi, 
physical  disability  is  at  any  rate  a  veiy  serious  disabling  con- 
dition at  the  time  of  application  of  three-fourths — not  one- 
fourth— of  all  the  families  that  come  under  the  care  of  the 
Charity  Organization  Society." 

Sickness  acts  as  a  double  cause  of  poverty.  There  is,  first 
the  direct  loss  due  to  the  cessation  of  regular  income  and. 


SICKNESS  AS  A  CAUSE  OF  POVEETY        17 

second,  the  loss  of  savings  due  to  expenses  for  doctors'  and 
nnrses*  fees  and  for  medical  supplies. 

The  loss  due  to  idleness  has  been  estimated  to  be  equal  to 
an  average  of  nine  days*  wages  per  year.  The  Pennsylvania 
Health  Insurance  Commission  estimated  that  in  that  state 
alone  employees  are  losing  more  than  $39,000,000  annually 
because  of  sickness.  In  the  Kensington  Survey  the  wage  loss 
was  reported  in  367  cases  and  averaged  $78.53  per  case.  In 
only  a  small  percentage  of  employees  are  wages  continued 
during  sickness,  probably  not  more  than  five  or  six  per  cent. 
Illness  may  act  further  to  increase  poverty  through  its  results. 
Frequently  after  an  attack  of  rheumatism  or  typhoid  or  other 
disease,  the  body  is  left  so  shattered  from  the  effects  of  the 
illness,  that  the  former  occupation  is  beyond  the  strength  of 
the  individual.  Consequently  a  new  and  lighter  occupation 
must  be  chosen  which  results  in  diminished  earning  power. 

The  expenditure  for  sickness  varies  considerably  in  different 
families  and  in  various  localities.  Many  of  the  poorer  families 
spend  as  much,  or  more,  for  patent  medicines  (self -medica- 
tion) as  they  do  for  medicines  prescribed  by  physicians.  In 
a  number  of  families  studied  in  Philadelphia,  the  average 
expenditure  for  this  purpose  was  over  $5.00  a  year.  In  a 
survey  by  the  United  States  Bureau  of  Labor  Statistics  the 
expenditures   for   medical   relief   of   families   with   varying 

income  was  studied  with  the  following  findings ; 


18        THE  COMMUNITY  HEALTH  PEOBLEM 

TXABLY  SZPEKDirnSES  FOB  8ICENSS8 

Washington,  D.  C,  1916 


Iiio(»ie 

Number 

of 
Fiunilies 

Yearly 
Expenditures 

Under  1600 

Total 

Whites 

Colored 

Total 

Whites 

Colored.... 

Total 

Whites 

Colored 

Total 

Whites 

Cdkned 

Total 

Whites 

Colored 

Total 

Whites 

Colored 

65 
45 
19 

235 
115 
118 

215 

167 

48 

209 

198 

11 

198 

191 

7 

922 
692 
230 

tl2.01 

$600-1900 

12.83 
10.03 

20.84 

f90O-|i;200 

26.52 
16.20 

40.19 

11.200-11  JKX) 

42.31 
32.84 

42.42 

Otertl»600 

43.16 
28.96 

68.71 

ATerage,  aU  mooxnes — 

69.67 
36.21 

37.76 
43.69 
20.19 

This  of  conrse  does  not  indude  the  free  treatment  at  chari- 
table institationa,  snch  as  hospitals  and  dispensaries,  -which 
would  amount  to  considerably  more.  Therefore  it  is  safe  to 
say  that  medical  attention  and  medical  supplies  cost  each 
family  at  least  $40  per  year  nnder  conditions  snch  as  exist 
in  la^  cities.  In  rural  districts  it  is  possible  that  the  ezpen* 
ditnre  is  b  little  less. 

Though  this  expenditure  is  not  large,  it  should,  if  it  were 
expended  scientifically  and  efficiently,  purchase  a  fairly  satis- 
factory medical  sendee.    However,  xmder  our  present  system 


SICKNESS  AS  A  CAUSE  OF  POVEBTY        19 

the  money  is  to  a  large  extent  not  well  spent.  In  the  first 
place  it  is  spent  almost  entirely  after  Uliiess  has  occnrred. 
Only  a  small  amount  is  devoted  to  the  prevention  of  disease. 
Compared  with  the  amount  spent  for  the  cure  of  illness  the 
community  spends  only  a  comparatively  insignificant  amount 
for  prevention,  possibly  from  one  to  three  dollars,*  per  capita, 
yearly  in  cities  and  very  much  less  in  most  rural  communities. 
In  the  next  place  the  care  of  illness  is  left  largely  to  the 
patient  himself.  When  he  decides  he  needs  medicine  he  pro- 
ceeds to  buy  patent  medicine;  when  he  thinks  he  needs  a 
doctor  he  secures  the  services  of  one,  if  he  can  afford  the 
expense,  only  when  he  is  convinced  that  there  is  no  other 
alternative.  In  many  cases  this  is  too  late  to  secure  the  best 
results.  The  physician,  being  paid  to  cure  disease  and  not  to 
prevent  it,  devotes  most  of  his  energies  to  curative  medicine 
and  very  little  to  prevention. 

The  experience  of  the  Bockefeller  Foundation  in  certain 
southern  communities  has  thrown  considerable  light  upon 
this  point.  In  certain  cases  they  have  found  that  by  expendi- 
tures  directed  toward  the  prevention  of  malaria  they  were 
able  to  reduce  malaria  almost  to  the  vanishing  point  and  this 
at  a  cost  of  less  than  had  previously  been  spent  for  treatment 
of  the  disease. 

In  an  experiment  carried  on  by  the  Foundation  in  Arkansas 
an  attempt  was  made  to  rid  four  towns  in  the  state  of  malarial 
infections  by  means  of  well  recognized  measures  for  the  exter- 
mination of  the  mosquito.  Pools  were  drained  or  filled,  slug- 
gish streams  were  ditched  and  oil  was  applied  to  surface  water 
which  could  not  be  otherwise  dealt  with.  In  other  words  the 
attempt  was  made  to  make  these  towns  unhealthy  places  for 
the  disease-carrying  mosquito. 

The  results  were  measured  by  the  number  of  visits  made  by 

physicians  to  patients  suffering  from  malaria.    In  1916,  before 

the  experiment,  the  number  of  calls  made  in  the  town  of  Ham- 

•Tb«  txpcndltnm  of  tbe  New  Tork  City  Department  of  Health  la  about 
00  centa  par  capita.  Thla  amonnt  la  increaaed  by  Stat*  and  Vedaral 
•zpendltnres  and  by  voluntary  donations. 


20        THE  COMMUNITY  HEALTH  PROBLEM 

hvLTg,  Arkansas,  was  2,312 ;  in  1917,  the  year  of  the  experi- 
ment, the  calls  dropped  to  259,  and  in  1918  to  59.* 

In  this  town  of  only  a  few  oyer  a  thousand  inhabitants  the 
per  capita  cost  of  the  conquest  of  malaria  was  $1.45  in  1917 
and  44  cents  in  1918. 

Similar  results  could  not  be  secured  in  every  community, 
but  there  are  many  towns  and  villages  in  the  United  States 
where  comparable  results  might  be  obtained. 

The  element  of  charity  in  free  medical  treatment,  whether 
provided  from  the  public  purse  or  by  charitable  organizations, 
has  prevented  a  certain  portion  of  the  community  from  accept- 
ing free  treatment  even  when  it  is  offered.  There  is  a  certain 
portion  of  the  population,  perilously  near  the  poverty  line 
which  resents  the  implication  that  it  is  unable  to  pay  for  med- 
ical care.  This  follows  closely  on  the  experience  of  the  early 
days  of  education..  The  "free  school"  was  for  the  very  poor,  the 
pay  school  for  the  well-to-do  and  nothing  for  the  middle  dass. 
Many  children  were  denied  the  benefits  of  education  because 
their  parents  refused  to  send  them  to  the  free  school.  It  is 
the  same  today  with  regard  to  medical  care.  Free  medical  care 
is  available  to  a  limited  extent  but  self  respecting  wage  earn- 
ers  often  prefer  to  do  without  treatment  ratiier  than  to  deprive 
others  who  may  be  more  in  need  of  help. 

It  is  easy  to  determine  for  yourself  the  effect  of  prolonged 
illness  as  a  cause  of  poverty  and  want.  Examine  a  given  num- 
ber of  wage  earners,  say  twenty  or  thirty,  and  find  out  how 
many  of  them  could  stand  the  financial  strain  of  a  disability 
lasting  six  months  or  longer.  Such  a  disability  might  easily 
occur  as  a  result  of  a  broken  thigh  or  an  attack  of  nephritis 
and  yet  only  a  few  have  enough  money  in  bank  to  b^^  to 
pay  the  necessary  expenses  of  such  a  long  illness.  Yet  scat- 
tered over  the  entire  population  such  a  period  of  disability 
occurs  comparatively  seldom  and  could  be  easily  met  by  some 
form  of  insurance. 

•B«fl«w  «(  the  Work  of  tilt  BeekcMlcr  reaadaMon  for  2818.    Pab- 
Usbtd  b7  tbo  Rockefeller  Foaodatlon,  New  York,  1919. 


SICKNESS  AS  A  CAUSE  OF  POVERTY        21 

The  advocates  of  health  insurance,  believing  in  the  princi- 
ples of  insurance  and  in  its  application  to  the  distrilration  of 
economic  loss  due  to  disease,  contend  that  the  enactment  of  a 
h^th  insurance  bill  will  diminish  poverty  which  may  arise 
because  of  ill  health.  They  point  to  the  experiences  of  Ger- 
many, where  poverty,  in  the  sense  in  which  we  see  it  in  our 
larger  cities,  was  practically  unknown  before  the  war,  as  an 
example  of  what  health  insurance  can  accomplish  for  the 
economic  regeneration  of  the  communties.  Because  of  the 
high  overhead  charges  of  any  form  of  voluntary  insurance, 
and  because  of  the  fact  that  in  commercial  voluntary  health 
insurance,  policies  are  seldom  taken  out  except  by  the  "dan- 
gerous risks"  thus  greatly  increasing  the  premium,  it  is 
claimed  that  if  health  insurance  is  to  be  successful  it  must 
be  made  compulsory  and  administered  by  the  state. 

The  opponents  of  health  insurance,  while  admitting  the 
value  of  insurance  in  general,  claim  that  the  word  "compul- 
sory*'  is  objectionable,  that  the  idea  of  compulsion  is 
un-American  and  that  health  insurance  is  impracticable  and 
unfair  to  the  physician  and  to  the  individual. 

Theoretically,  if  we  accept  nine  days  as  correct  for  the 
average  yearly  disability  for  all  workers  it  would  seem  that 
if  each  worker  contributed  nine  days'  wages  to  a  general  fund, 
to  be  expended  in  benefits  to  those  disabled  by  injury  or  dis- 
ease, the  figures  should  balance  and  sickness  would  cease  to 
act  as  a  cause  of  poverty. 

While  the  workman  has  been  willing  to  purchase  fire  insur- 
ance on  his  home  and  life  insurance  on  his  person  he  has 
never  taken  to  sickness  insurance  and  his  savings  against 
future  sickness  are  usually  entirely  inadequate. 

There  must  be  found  for  the  benefit  of  all  a  workable 
method  which  will  greatly  diminish  the  economic  loss  to  the 
individual  arising  out  of  serious  injury  and  protracted  illness, 
and  the  search  for  such  a  method  constitutes  a  large  part  of 
the  community  health  problem  as  it  is  presented  to  us  today. 
Workmen's  compensation  insurance,  which  applies  to  injuries 


^ 


22        THE  COMMTTNITY  HEALTH  PROBLEM 

incurred  during  employment,  has  done  a  great  deal  to  diminisli 
part  of  the  poverty  arising  from  injuries,  and  it  is  possible 
that  similar  measures  may  be  applied  to  non-industrial 
injuries  and  to  at  least  a  part  of  the  disability  due  to  disease. 

The  following  is  taken  from  the  Report  of  the  Special  Committee  on 
Social  Insurance  of  the  American  Medical  Association:  "As  a  reaolt  of 
an  inyestigation  covering  forty-three  cities  and  over  30,000  charity  cases, 
the  United  States  Immigration  Commission  found  that  illness  of  the 
bread-winner  or  other  member  of  the  famllv  was  a  factor  in  38Ji  per 
cent,  of  the  cases  of  those  seeking  aid.  In  New  York  City  sickness  or 
deformity  was  present  in  two-thirds  of  the  3,000  families  assisted  by  the 
charity  organization  in  1918:  in  Chicago,  sickness  is  reported  as  the 
primary  factor  in  26  per  cent,  of  the  cases  cared  for  in  1017  and  as  a 
contribatory  factor  in  45  per  cent,  of  the  other  cases;  in  San  Francisco 
and  Los  Angeles,  sickness  was  the  primary  cause  of  destitution  In  CO 
per  cent  of  over  5,000  charitable  cases."  (Social  Insaranc*  BerlM, 
Pamphlet  No.  XI.  American  Medical  ArsoclaUon,  Idld). 


CHAPTBE  III 
THE  PRIVATE  PHYSICIAN  AND  COMMUNITY  HEALTH 

If  we  accept  as  true  the  statement  that  there  is  constantly 
a  large  number  of  persons  in  every  community  who  are  seri- 
ously ill  and  that  a  certain  considerable  percentage  of  sickness 
is  either  preventable  or  requires  treatment,  it  becomes  neces- 
sary to  examine  the  present  facilities  for  prevention  of  disease 
and  for  the  treatment  of  illness  when  it  occurs,  in  order  to 
determine  whether  every  reasonable  effort  is  being  made  to 
diminish  preventable  diseases  and  whether  all  eases  of  illness 
are  receiving  adequate  -medical  attention. 

Medical  practice  in  the  United  States  is  based  primarily 
upon  the  work  of  the  private  physician.  The  laws  of  most  of 
the  states  recognize  the  responsibilities  of  the  private  prac- 
titioner and,  within  certain  limits,  define  the  educational 
requirements  which  a  physician  must  satisfy  in  order  to  prac- 
tice his  professon. 

Within  these  limits,  however,  medical  treatment  varies 
according  to  the  physician  employed.  In  some  states  various 
schools  of  osteopathy,  chiropractic,  neuropathy,  and  mental 
healing  all  receive  recognition  and  the  patient  may  receive 
treatment  by  practitioners  of  any  of  these  schools.  There  is 
often  no  general  supervision  of  health  conditions  except  in 
matters  of  infectious  and  contagious  disease  and  even  in  such 
patients  the  measures  enforced  by  the  community  often  have 
to  do  with  quarantine  rather  than  treatment.  As  a  rule,  com- 
munity requirements  are  satisfied  when  a  patient  suffering 
from  acute  or  chronic  illness  is  under  the  care  of  a  medical 
practitioner.  In  general,  only  in  the  case  of  contagious 
disease,  and  then  only  to  a  limited  extent,  does  the  state 
attempt  to  Qualify  the  character  of  the  treatment  given. 

23 


24        THE  COMMUNITY  HEALTH  PROBLEM 

The  interests  of  the  commmiity  are,  theoretically,  mider  the 
care  of  the  state  and  local  departments  of  health,  which  as  a 
rule,  have  an  adyisory  relation  to  the  private  physician,  and 
certain  police  powers  affecting  hoth  the  physician  and  the 
puhlic 

It  is  the  purpose  at  this  time  to  discuss  chiefly  the  relation 
of  the  private  physician  to  sickness  in  the  community,  disre- 
garding, for  the  time  being,  the  limited  control  by  the  state 
and  by  voluntary  associations. 

If  we  examine  the  history  of  medicine  we  see  that  there 
have  been  three  stages  of  progress  in  the  practice  of  medicine. 
During  the  first  stage  it  was  believed  that  illness  was  the  work 
of  evil  spirits,  and  that  charms  and  incantations  would  drive 
the  evil  spirits  from  those  afflicted.  At  a  later  date  disease 
was  thought  to  be  due  to  various  'Hiumors''  which  might  ba 
expelled  from  the  body  by  the  use  of  various  medicaments. 
Examples  of  believers  in  the  first  stage  stUl  exist  in  the 
followers  of  so-called  "faith"  cures  and  of  the  second  stage 
among  those  who  make  possible  the  dividends  of  the  patent 
medicine  manufacturers.  Tonics,  blood  purifiers,  and  other 
drugs  of  a  similar  nature  are  sold  in  tremendous  quantities 
largely  as  a  result  of  advertisements  in  newspapers  and  lay 
magazines  with  a  resulting  enormous  amount  of  self  medica- 
tion for  which  there  is  no  scientific  basis. 

"The  third  or  modem  stage,"  says  Dr.  William  Brend,*  is 
based  upon  scientific  study  of  disease  and  the  human  body. 
Exact  diagnosis  of  the  malady  is  the  first  step  and  efforts  are 
then  made  to  cure  it  which  bear,  as  far  as  possible,  distinct 
relation  to  its  cause.  For  these  purposes  medicine  no  longer 
blindly  administers  nauseous  compounds,  but  calls  to  its  aid 
physiology,  anatomy,  chemictry,  physics  and  other  sciences 
and  at  the  same  time  studies  the  constitution  of  the  patient 
and  his  surroundings  including  in  its  treatment  suitable  diet- 
ing, nursing  care  and  hygienic  surroundings.'' 

During  the  last  fifty  years  there  have  been  vast  changes  in 
medical  science.   The  known  facts  have  increased  so  rapidly 

•Bresd.  WUUazB  A.:  Health  tnd  th«  State.  London,  1917,  p.  ISL 


PHYSICIAN  AND  COMMUNITY  HEALTH      25 

that  it  is  impossible  for  any  man  to  master  the  details  of  all 
branches  of  the  profession.  The  technic  of  surgery  has  become 
80  specialized  that  men  spend  years  mastering  the  operative 
technic  of  a  single  part  of  the  body  such  as  the  eye  or  ear. 
As  a  result  specialism  has  rapidly  developed  and  the  import- 
ance of  the  general  practitioner  has  steadily  declined. 

The  private  physician  practices  little  or  no  preventive  medi- 
cine. He  is  ordinarily  called  only  when  the  patient,  of  his 
own  accord,  decides  that  he  is  sick  and  requires  medical 
attention.  The  physician  seldom  sees  his  patients  unless  they 
send  for  him.  Except  for  vaccination  against  small  pox, 
which  is  required  by  law,  and  advice  to  persons  exposed  in 
cases  of  infectious  disease,  his  efforts  are  con£ned  almost 
entirely  to  the  cure  of  illness.  He  has,  as  a  rule,  neither  the 
e3q)erience  nor  the  time  to  practice  preventive  medicine. 

For  economic  reasons  preventive  medicine  as  such  must 
depend  upon  community  effort  either  local  or  general.  In  the 
United  States,  most  preventive  measures  have  been  under- 
taken either  by  the  public  health  authorities  or  by  voluntary 
(Organizations  working  for  the  public  welfare. 

Admitting  that  it  is  impossible  for  the  private  physician 
to  devote  much  time  to  preventive  medicine,  let  us  examine 
the  present  system  of  medical  treatment  which  is  largely 
under  the  control  of  the  private  practitioner. 

Does  the  present  system  of  medical  treatment  supply  ade- 
quate facilities  for  the  care  of  disease?  Does  private  practice 
supply  modem  scientific  medical  treatment  to  a  reasonable 
extent  for  the  bulk  of  the  population?  If  these  questions  are 
answered  in  the  affirmative  then  the  communiiy  health  prob- 
lem is  limited  to  prevention  and  to  the  care  of  the  pauper  class 
only  and  is  much  simplified.  If  the  large  amount  of  sickness 
is  unavoidable  and  is  at  present  receiving  every  necessary 
attention  then  we  have  only  to  devote  ourselves  to  the  pre- 
vention of  charlatanism  and  medical  quackery,  avoiding  so  far 
as  possible  any  interference  with  the  existing  order. 

However,  there  is,  unfortunately,  considerable  evidence  that 
the  private  practice  of  medicine,  except  for  its  function  of 


26        THE  COMMUNITY  HEALTH  PBOBLEM 

fumiBhing  a  livelihood  for  the  doctor,  is  a  partial  failure,  in 
that  it  fails  signally  to  furnish  either  adequate  medical  care 
or  modem  scientific  medicine  to  a  large  part  of  the  popu- 
lation. 

The  average  physician  practices  medicine  primarily  as  a 
means  of  livelihood.  From  the  nature  of  his  profession  the 
humanitarian  aspect  of  modem  life  is  seen  more  clearly  than 
in  most  other  professions  but,  in  the  last  analysis,  he  must 
receive  adequate  remuneration  or  cease  to  exist.  Consequently 
he  must  either  devote  a  small  part  of  his  time  to  patients 
financially  able  to  pay  large  fees,  thereby  permitting  him  to 
give  a  part  of  his  time  to  charity  patients  from  whom  he 
obtains  his  fund  of  clinical  experience;  or,  he  must  make  a 
large  number  of  visits  upon  patients  able  to  pay  a  small  or 
moderate  fee.  Patients  of  this  latter  class  are  usually  unable 
to  bear  the  additional  burden  of  the  expense  of  specialists  and 
laboratory  fees  required  by  modem  medicine  and  are,  as  a  con- 
sequence, deprived  of  the  expert  service  which  they  often 
require.  As  a  result  they  often  lose  confidence  in  the  medical 
practitioner  and,  if  unable  to  pay  the  fees  of  the  specialist, 
resort  to  home  remedies  or  patent  medicines.  It  is  among 
such  patients  that  self  medication  is  most  widespread. 

In  the  families  of  workmen  in  New  York  City  medical 
treatment  costs  from  one  to  three  dollars  a  visit.  For  ordinaiy 
cases  this  secures  good  treatment  but  for  complicated  cases 
where  laboratory  examinations  and  radiographs  are  required 
the  additional  fee  becomes  a  heavy  burden  and  consequently 
the  necessary  examinations  are  often  neglected.  This  results 
in  unscientific  and  unsatisfactory  medical  treatment  and  often 
in  lasting  injury  to  the  patient. 

In  the  sickness  surveys  made  by  the  Metropolitan  life  In- 
surance Company*  from  1915  to  1917,  in  widely  separated 
communities,  from  27  to  39  per  cent,  of  the  persons  ill  were 
found  to  be  without  a  physician  in  attendance,  these  surveys 
including  only  "eerious**  illnesses.    In  six  surveys  covering 

*  Social  Inanrance:  Report  of  the  Special  Committee  of  the  American 
MMlcal  AsaoeUtion  for  Ul»,  p.  45. 


PHYSICIAN  AND  COMMUNITY  HEALTH      27 

some  13,000  persoos  eerioiuly  ill,  almost  4,000  or  about  30  per 
cent  were  having  no  medical  care  whatsoever. 

In  a  somewhat  similar  survey  made  in  Dutches  Coonly, 
New  York,  in  1912-13  and  covering  approximately  10,000 
persons,  oidy  76  per  cent,  of  those  ill  were  nnder  the  care  of 
a  physician.  An  examination  of  those  sick  in  Framingham, 
Mass.,  showed  81  per  cent,  nnder  a  physicians's  care,  while  in 
the  mral  districts  surrounding  Framingham  more  than  53 
per  cent,  of  those  sick  were  receiving  ^solutely  no  medical 
attention.  . 

Of  1726  dispensary  patients  studied  in  Boston,  72  per  cent, 
had  had  no  previous  medical  care  and,  of  these,  35  per  cent, 
had  been  sick  more  &an  three  months. 

It  would  be  possible  to  continue  similar  statistics  almost 
indefinitely.  While  the  percentage  varies  there  is  regularly  a 
large  portion  of  the  population  who  receive  no  medical  care 
when  ilL  ., 

The  causes  of  this  failure  may  be  classed  under  three  head- 
ings:  1.  Economy;  2.  Distrust;  3.  Ignorance. 

Economy  is  no  doubt  the  most  potent  factor.  Expenses 
devoted  to  medical  care  are  seldom  foreseen  and  consequently 
their  burden  is  doubly  hard  to  bear.  Moreover,  the  working 
man  feels  that  a  charge  of  two  or  three  dollars  represents 
more  than  he  can  afford  and  he  puts  off  calling  the  physician 
as  long  as  possible,  trusting  that  he  will  escape  serious  con- 
sequences. 

Distrust  of  the  physician  or  of  the  medical  profession  in 
general  is  a  fairly  frequent  cause  of  lack  of  medical  care. 
Some  persons,  because  of  a  previous  disagreeable  experience 
at  the  hands  of  an  imscrupulous  doctor,  will  delay  calling  a 
physician  when  next  they  become  ilL  Qeneral  distrust  such  as 
is  fostered  by  patent  medicine  interests,  and  medical  cults, 
also  accounts  for  a  certain  number  of  non-treatment  cases. 

Ignorance  both  of  the  cause  and  symptoms  of  disease  is  a 
rather  potent  factor.  It  is  not  uncommon  to  'see  a  patient 
suffering  from  pulmonary  tuberculosis  with  a  temperature  of 
102  degrees,  or  over,  who  for  months  attempts  to  cure  his 


i' 


28        THE  COMMUNITY  HEALTH  PEOBLEM 

conditioii  by  exercise  under  the  impression  that  his  symptomsy 
weakness  and  loss  of  weight,  are  the  result  of  sedentary  habits. 
Under  this  same  heading  may  be  placed  the  ignorance  of  the 
patent  medicine  advertisement  reader  ''who  knows  a  lot  but 
knows  it  wrong."  Their  partial  knowledge  of  the  subject 
allows  them  to  be  made  easy  dupes  of  the  clever  advertise- 
ment writers  so  that  pain  in  the  back,  occasionally  an  early 
symptom  of  tuberculosis  of  the  spine,  is  treated  for  months  ' 
with  "Curem's  Kidney  Bemedy"  so  that  when  seen  by  the 
physician  the  disease  has  progressed  beyond  the  favorable 
stage. 

The  medical  profession  devotes  an  enormous  amount  of 
time  to  the  care  of  charity  cases  but  in  spite  of  this  is  failing 
to  fulfil  its  full  duty  to  the  community.  It  fails  not  because 
t  does  not  give  its  best  efforts  to  the  sick  but  because  it  does 
ot,  as  a  whole,  appreciate  the  community  problem  and  has  not 
succeeded  in  reaching  the  bulk  of  the  population  with  any 
marked  degree  of  success. 

Cabot  has  drawn  attention  to  what  was,  until  recently,  the 
prevailing  method  of  treating  heart  disease  in  the  best  type 
of  metropolitan  hospitals.  The  patient,  admitted  in  bad  con- 
edition,  after  several  weeks  of  treatment  was  usually  suflBciently 
improved  to  be  able  to  be  up  and  around  the  ward  without 
shortness  of  breath  or  subjective  evidence  of  his  leaky  valve. 
He  was  then  discharged  from  the  hospital  with  the  advice 
to  **take  things  easy."  In  most  cases,  however,  for  eco- 
nomic reasons,  he  was  obliged  to  seek  work,  and  attempt- 
ing work  which  was  too  hard  for  the  weakened  condition 
of  his  heart  he  soon  broke  down  and  was  obliged  to  return 
to  the  hospital  for  further  treatment.  This  process  was 
repeated  over  and  over  again  to  the  economic  loss  of  the. 
man,  the  community  and  the  hospital.  Recently  this  has 
been  changed  by  the  follow-up  system  of  after-eare  intro- 
duced in  many  hospitals  which  not  only  provides  the  sub- 
normal individual  with  medical  advice  but  actually  under- 
takes the  placing  of  such  persons  in  suitable  occupations. 

With  the  advance  of  medical  science  the  mortality  rates  of 


PHYSICIAN  AND  COMMUNITY  HEALTH      29 

most  great  cities  have  steadily  fallen  and  the  span  of  human 
life  has  generally  increased.  This  is  largely  the  result  of  the 
application  of  what  wise  physicians  and  skilled  surgeons  have 
taught  regarding  the  cure  of  disease.  Men  of  science  are  devot- 
ing their  lives  to  the  problem  of  disease  and  may  be  expected 
in  the  future  to  develop  new  methods  of  prevention  and  cure. 
Typhoid,  small-pox,  nialaria,  and  diphtheria  are  rapidly  dis- 
appearing. Many  other  diseases  such  as  tubercniosia  and  dia^ 
betes,  are  more  successfully  treated  today  than  ever  before. 
Cancer  is  only  partially  conquered  by  surgical  measures,  but 
experimental  results  obtained  give  hope  that  sooner  or  later 
a  clear  understanding  of  the  cause  and  a  rational  method  of 
treatment  may  be  discovered. 

The  community  problem  today  is  not  concerned  with  the 
search  of  new  ways  and  means  for  the  cure  of  existing  disease, 
such  search  may  weU  be  left  to  hospitals  and  scientific  insti- 
tutions. The  real  problem  before  ^e  community  is  that  of 
making  proper  use  of  the  tools  at  hand,  so  that  modem  sci- 
entific methods  of  treatment  may  be  available  to  each  and 
every  citizen,  whether  rich  or  poor.*  To  this  end  the  medical 
service  must  be  reorganized  so  that  the  services  of  the  gen- 
eral practitioner,  the  specialist  and  the  medical  laboratory 
may  be  secured  by  the  sick  in  the  community  at  an  equable 
cosl  The  present  system  of  charging  what  the  traffic  will  bear 
must  be  discarded. 

*  "Tb«  remedy  for  this  sltaatlon  (labor  scarcity  da«  to  Injory  and 
disease).  lies  economically  In  a  redistribution  of  costs,  not  of  adding 
sew  costs,  but  rearranging  the  present  method  of  expending  the  costs 
already  being  expended.  .  .  .  Improved  medical  care  mast  come  from 
more  co-operative  and  leas  purely  Indivldnallstlc  care  from  the  medical 
profession."  (Report  of  Special  Conunltte*  on  Social  Insurance,  Amarl- 
can  Medical  AMOClatios.  I9ld). 


•> 


CHAPTBB  IV 
HEALTH  DEPARTMENTS  AND  COMMUNITY  HEALTH 

In  the  pierention  of  disease,  much  depends  npon  the  pnblio 
health  authorities.  As  ordinarily  used  the  term  public  health 
includes  all  forms  of  federal,  state,  county,  or  municipal  activi- 
ties which  may  influence  the  morbidity  or  mortality  rates  of  a 
communiiy.  A  public  health  officer  is  usually  an  employee  of 
the  local  or  state  government  by  which  he  is  paid  and  from 
which  he  receives  his  authority  to  act.  Under  our  present 
system  the  public  health  official  devotes  his  time  almost 
entirely  to  prevention  and  sanitation. 

Until  comparatively  recently,  public  health  officers  were 
poorly  paid  and  served  mainly  as  police  officers  to  enforce 
sanitary  regulation.  In  recent  years,  however,  the  work  of  the 
public  health  officer  has  broadened  in  its  scope  and  is  now 
concerned  not  only  with  sanitation  in  the  narrower  sense, 
but  also  with  hygiene,  housing,  child  welfare,  and  numerous 
other  health  meaenme  for  the  prevention  and  control  of 
diseasIL 

ProfeMor  "Winalow,  of  Tak,  has  expressed  this  broader  view 
of  poblic  health  in  an  address  b«f  ore  the  American  Associataon 
for  the  Advancement  of  Science.*  "Public  health,"  he  says, 
'*is  the  science  and  art  of  prevwiting  disease,  prolonging  life, 
and  promoting  health  and  efficiency  through  organized  com- 
munity efforts  for  sanitation,  the  control  of  infection,  the  edu- 
cation of  the  individual  in  the  principles  of  personal  hygiene, 
the  organization  of  the  medical  and  nursing  service  for  the 
early  diagnosis  and  preventive  treatment  of  disease,  and  tiie 

•window,  C.  B.  A.:  Th»  UntUled  TlsldB  of  Public  BMlth.  Bdmot, 
Jmn.  9,  nOO. 

30 


DEPARTMENTS  AND  COMMUNITY  HEALTH    31 

development  of  social  machinery  which  will  insure  to  eveiy 
individual  in  the  community  a  standard  of  living  adequate 
iss  tkfl  maintttoance  of  health/' 

TBB   UNITED  STATES   PUBXJO   HEALTH  SSBTICB 

The  federal  health  service  has  grown  rapidly  during  recent 
years,  especially  during  the  war  period.  Originally  concerned 
chiefly  with  quarantine  and  the  administration  of  marine 
hospitals  and  with  an  appropriation  of  less  than  a  million 
dollars  yearly,  the  service  has  rapidly  increased,  so  that  in 
1920  the  annual  appropriation  was'  approximately  $18,000,000. 

In  1919  the  commissioned  personnel  of  the  Public  Health 
Service  consisted  of  a  Surgeon-General  and  217  medical  o£Q- 
cars  of  various  grades.  In  addition  there  were  526  commia- 
aioned  to  the  reserve  of  whom  222  were  on  active  service. 

Since  the  war,  the  work  of  the  service  has  greatly  increased, 
due  largely  to  the  fact  tiiat  all  medical  care  of  discharged 
soldiers,  sailors  and  marines,  made  necessary  as  a  result  of 
injuries  or  diseases  incurred  in  service,  was  turned  over  to 
the  medical  oflBcers  of  the  Public  Health  Service.  In  addition 
the  medical  examinations  required  by  the  Bureau  of  War  Bisk 
Insurance  were  made  chiefly  by  commissioned  or  reserve  pub- 
lic health  officers. 

Space  does  not  permit  more  than  a  brief  outline  of  the  after- 
the-war  program  planned  by  the  Public  Health  Service.*  The 
program  in  brief  is  as  follows : 

1.  Industrial  hygiene : — Health  surveys  in  industry  are  to 
be  continued  and  extended  and  minimum  standards  are  to  be 
established.  Go-operation  with  state  and  local  officers  in  the 
sanitation  of  industrial  communities  is  to  be  developed. 

2.  Rural  hygiene : — Federal  aid  is  to  be  made  available  for 
the  maintenance  of  adequate  county  health  organizations. 
Such  aid  is  not  to  exceed  one-half  the  expense  of  intensive 
rural  health  work.  Investigation  and  trained  assistance  is  to 
be  given  in  campaigns  for  better  rural  sanitation. 

•laniul  Bcport  for  1919.  U.  &  Pvbllc  BMltb  Btirriee,  WoUagtoa,  D.  a 


32        THE  COMMUNITY  HEALTH  PBOBLEM 

3.  Prevention  of  the  diseaaea  of  infancy  and  childhood : — 
There  has  been  a  comprehensiTe  program  arranged  including 
pre-natal  care,  child  welfare,  physical  examination  of  children 
and  anperriaion  of  children  dnring  the  school  age. 

4.  Water  Supplies: — Surveys  of  water  supplies  arc  to  he 
made  and  recommendations  are  to  be  made  to  local  authorities 
for  the  improvement  of  the  local  water  supply. 

5.  Milk  supplies: — ^This  part  of  the  work  includes  a  cam- 
paign for  universal  pasteurization  and  adequate  inspection  of 
all  milk  supplies. 

6.  Sewage  disposal : — ^It  is  believed  that  proper  sewage  dis- 
posal will  greatly  diminish  intestinal  diseases  such  as  typhoid 
fever,  dysentery,  etc. 

7.  Malaria : — National  development  of  measures  to  oontrol 
malaria  is  contemplated. 

8.  Venereal  diseases: — ^A  comprehensive  campaign  against 
venereal  disease  is  planned. 

9.  Tuberculosis: — ^The  control  of  tuberculosis  is  to  be  at- 
tempted through  the  stringent  provision  for  reporting  cases, 
adequate  instruction  for  families  and  patients,  and  hospitali- 
zation of  cases  wherever  practicable. 

In  addition  to  the  above  there  is  a  plan  for  the  develop* 
ment  of  better  railway  and  municipal  sanitation  together  with 
the  promulgation  by  the  Public  Health  Service  of  health 
standards  and  other  subjects  connected  with  health  and  sani- 
tation. Th^  also  hope  to  increase  the  available  morbidity 
reports  by  records  obtained  from  the  industrial  group  of  the 
population  through  tiie  appointment  of  industrial  surgeons 
as  special  sanitai^  officers. 

It  may  be  seen  from  the  above  that  the  Public  Health  Serv- 
ice should  be  an  active  factor  in  the  solution  of  the  com- 
mnnity  health  problem.  like  ihe  Bockefeller  Foundation  the 
Public  Health  Service  does  not,  except  in  a  few  cases,  attempt 
the  actual  care  of  the  individual  but  attempts  to  demonstrate 
to  the  local  community  the  modem  and  sci^tifc  method  of 
health  oontroL 


DEPAETMENTS  AND  COMMUNITY  HEALTH    33 

STATE  HEALTH  DEPAETMENTS 

\  Public  health,  "under  the  state  system  of  government,  is 
largely  a  function  of  the  State.  Theoretically  the  Federal 
health  service  has  to  do  only  with  interstate  health  problems 
and  the  care  of  employees  of  the  Federal  Government. 
Actually  through  the  control  of  interstate  commerce  the 
United  States  Government  can  take  a  considerable  part  in 
shaping  the  health  policies  of  the  various  states. 

State  Departments  of  Health  are  ordinarily  under  the  con- 
trol of  a  commissioner  who  is  appointed  by  the  Governor. 
They  receive  their  power  from  the  state  legislatures  and  as  a 
consequence  their  functions  vary  considerably  in  different 
states.  In  the  more  progressive  states  their  powers  and  func- 
tions are  broad  and  their  control  over  community  health  is 
considerable.  In  other  states  their  duties  are  confined  almost 
entirely  to  the  recording  of  statistics  and  more  or  less  per- 
functory efforts  to  control  disease.  In  many  states  the  health 
boards  are  notably  lax  so  that  statistical  data,  even  in  refer- 
ence to  births  and  deaths,  is  so  incomplete  as  to  be  without 
value. 

Until  recently  it  has  been  very  difficult  to  organize  an 
efficient  state  health  department.  There  have  been  several 
reasons  for  this.  In  the  first  place  it  has  been  difficult  to  get 
sufficient  appropriations  so  that  the  department  is  frequently 
limited  in  its  activities  because  of  lack  of  funds.  In  the  next 
place  the  health  laws  are  often  not  correlated,  the  powers  of  the 
,  department  being  limited,  and  health  functions  often  divided 
among  several  different  commissions.  And  finally  it  has  been 
difficult  to  secure  efficient  health  officers  because  positions  are 
frequently  under  political  contrd  and  the  financial  rewards 
are  much  less  than  could  be  obtained  from  private  practice. 

In  spite  of  these  difficulties  there  has  been  a  steady  advance 
in  the  standing  of  the  state  health  departments  and  within 
the  last  few  years  certain  states,  notably  Ohio  and  North 
Carolina,  have  undertaken  progressive  measures  for  the  state- 
wide improvement  of  public  health. 


^. 


34       THE  COMMUNITY  HEALTH  PBOBLEM 

LOCAL  HEALTH   DEPAfiTlCEHTS 

In  the  commimitj,  health  fimctioiiB  are  nsnallj  under 
tile  control  of  the  mnnicipal  or  township  health  board  which 
receives  its  powers  in  part  from  the  state  and  in  part  from 
local  sources.  Such  health  boards  are  often  very  well  de- 
veloped in  large  vities  such  as  Chicago  and  New  York,  In 
smaller  cities  the  health  activities  are  often  veiy  inadeqnate 
and  in  villages  and  rural  commnnities  of  some  states  there 
is  often  no  community  health  effort  worthy  of  the  name. 

An  examination  into  the  expenditures  for  public  health  in 
various  localities  shows  great  variations.  Indeed  it  is  ex- 
tremely hard  to  compare  the  expenses  in  different  cities 
because  of  the  fact  that  in  one  diy  the  expenses  of  the  health 
department  may  include  such  items  as  removal  of  garbage, 
or  disposal  of  sewage,  and  in  another  these  items  are  charged 
to  other  departments.  However,  even  allowing  for  these 
factors  there  is  still  a  great  difference  in  expenditures  for 
health  in  different  localities. 

In  some  states  annual  appropriation  of  the  state  health 
department  is  less  than  five  cents  per  capita.  It  is  rarely  over 
ten  or  fifteen  cents  per  capita  even  in  states  otherwise  most 
progressive.  In  the  large  cities  the  expense  of  the  health 
board  is  considerably  higher.  In  Chicago,  for  example,  the 
yearly  health  expenditures  amount  to  over  forty-five  cents  per 
capita.  In  some  of  the  smaller  cities  the  amount  drops  to  a 
few  cents  per  capita  and  in  certain  rural  communities  practi- 
cally nothing  is  spent  for  public  health. 

Money  spent  in  the  prevention  of  disease  should  be  looked 
upon  as  insurance.  From  statistical  studies  it  is  certain  that, 
up  to  a  certain  amount,  money  spent  for  better  health  is 
returned  to  the  community  in  terms  of  diminished  disability 
and  decreased  financial  loss  due  to  sickness. 

However  it  is  often  hard  to  prove  this  to  the  taxpayers  prin- 
cipally because  the  money  must  be  expended  largely  for  per- 
sonal service  and  the  results  are  difficult  to  visualize.  Certainly 
much  larger  expenditures  should  be  made  for  public  health. 


v> 


DEPARTMENTS  AND  COMMUNITY  HEALTH    36 

The  total  even  of  several  dollars  per  capita  does  not  sound 
fizoeedve  viewed  in  the  abstract  but  when  it  comet  befor«  the 
state  legisUttre,  or  local  government,  for  appropriation  it 
appears  enormons.  The  health  officer  of  today  mnst  do  his 
best  to  demonstrate  what  can  be  done  with  small  appropria- 
tions and  trust  that  pnblic  opinion  will  support  him  in  requests 
for  more  funds  in  the  future. 

Doctor  Hemenway  has  studied  the  expenses  of  some  of  the 
cities  of  Illinois.  By  a  rather  elaborate  computation  he  has 
compared  the  expenses  for  health  with  the  estimated  losses 
due  to  cozmnunicable  disease.  While  it  is  possible  to  criticize 
Ms  results  because  of  the  difficulty  in  arriving  at  a  definite 
figure  representing  financial  losses  due  to  sickness,  the  figures 
are  accurate  within  certain  limits. 

The  result  of  his  inquiry  is  shown  by  the  following  table: 

TABLE  OF  PES  CAPITA  APPBOPBIATIOVS  AND  LOSSES* 

HeaUk  Sieknets         Per  Capita 

City  Appropriation       Losset    Annual  Vcduation 

Evanston    $0.31  $12.82  $473. 

Bloomington   0.13  23.60  332. 

Eockford   0.80  22.74  433. 

Waukegan    0.08  17.45  174. 

North  Chicago 0.03  41.40  216. 

East  St.  Louis 0.13  28.05  192. 

BelleviUe   0.14  26.83  239. 

Alton 0.08  38.41  193. 

Springfield 0.14  24.32  251. 

Decatur 0.177  17.48  234. 

Chicago   0.454  26.21  421. 

While  a  strict  comparison  of  figures  in  the  above  table  is 
not  possible,  because  so  many  other  elements  may  effect  public 
health,  yet  it  is  apparent  that,  in  general,  money  appropriated 
for  public  health  resulted  in  diminished  losses.  It  is  pointed 
out  that  Waukegan  and  North  Chicago  are  contiguous  and 

*H«menwa7,  Eenry  Bixby:  BconomlcB  of  Be«Itk  Admlnlstnitloo. 
Amtzican  Jounwl  of  Pnblic  Healtb,  Febraary,  1920. 


36        THE  COMMUNITY  HEALTH  PROBLEM 

represent  similar  commimities,  yet  Wankegan  at  an  expense 
of  6  cents  more  per  capita  shows  a  loss  of  only  $17.45  per 
capita,  $23.95  less  than  North  Chicago.  The  table  would 
also  indicate  that  in  smaller  cities,  such  as  Bockford  and 
Springfield,  a  smaller  expenditure  is  required  than  in  a 
large  city  such  as  Chicago. 

The  modem  tendency  is  toward  the  concentration  of  public 
health  activities  in  communities  large  enough  to  secure  the 
services  of  a  full  time  medical  ofl&cer.  In  Ohio  the  state  health 
department  was  reorganized  through  what  is  known  as  the 
Hughes  Act  which  divided  the  state  into  various  administra- 
tive districts.  The  village  and  township  health  officers  who 
were  previously  paid  very  small  salaries  were  to  have  been  re- 
placed by  district  health  officers  who  were  to  be  paid  salaries 
sufficiently  large  to  secure  a  full  time  health  officer.  One  or 
more  visiting  nurses  and  a  clerk  were  recommended  for  each, 
district  office.  The  district  supplies  a  part  of  the  fund  and 
the  state  aids  by  a  subsidy  which  varies  in  amount  according 
to  the  district  appropriation  up  to  a  maximum  of  $2,000 
yearly.  In  general  the  districts  follow  county  lines  except 
that  cities  usually  represent  a  separate  administrative  dis- 
trict. Unfortunately  just  before  the  Hughes  Act  went  into 
effect  it  was  amended  so  that  many  of  the  expected  benefits 
were  nullified.  It  is  understood  that  the  changes  were  made 
because  the  local  communities  rebelled  at  paying  the  addi- 
tional taxes  required  in  order  to  carry  out  the  provisions  of 
the  original  act. 

North  CMolina  has  also  made  considerable  advance  along 
similar  lines  aided  by  expert  advice  and  financial  assistance 
from  the  Rockefeller  Foundation.  In  many  rural  districts 
the  North  Carolina  Board  of  Health  lias  gone  out  of  its  way 
to  seek  out  school  children  who  are  in  need  of  treatment. 
Traveling  free  dental  clinics  and  free  operative  clinics  for 
the  removal  of  tonsils  and  adenoids  have  reached  an  enormous 
number  of  children  throughout  the  state.  In  an  editorial  in 
the  monthly  Health  Bulletin*  the  following  statement  is 

•The  Health  BnUctin,  North  C&rolliui  State  Board  of  Health,  NoTtm* 
bar,  1M9. 


>•> 


DEPARTMENTS  AND  COMMUNITY  HEALTH    37 

made :  "The  State  Board  of  Health  is  finding  daily  what  every 
physician  practising  in  the  smaller  towns  and  in  the  countzy 
has  always  known,  and  that  is  the  urgent  necessity  for  hos- 
pital  and  medical  service  which  will  reach  the  great  majority 
of  the  people  in  time  to  prevent  neglect  and  suffering  espe- 
cially among  children.  It  is  one  of  the  great  sociological 
problems  which  must  be  settled.** 

The  new  departures  in  North  Carolina  and  Ohio  are 
breaking  a  path  which  must  be  followed  by  the  health  depart- 
ments of  other  states.  Whether  the  road  leads  to  state  medi- 
cine or  to  health  insurance  or  to  some  other  form  of  com- 
munity effort  for  the  prevention  of  disease  is  not  dear.  At 
all  events  it  is  a  step  in  the  right  direction. 


0b 


CHAPTEB  y 

FUBUG  HEALTH  NURSING 

The  development  of  nuramg  has  led  to  the  claasification  of 
trained  nurses  in  three  distinct  groups ;  institutional  nurses— 
those  working  in  hospitals,  sanitaria  and  other  similar  insti-  ^ 
tutions;  private  nurses — ^those  giving  continuous  care  to  pri- 
vate patients ;  and  public  health  nurses — who  are  in  the  main 
engaged  in  some  form  of  social  work  closely  related  to  public 
health.  The  work  of  the  last  group  is  classified  under  the 
heading  **public  health  nursing"  and  includes  visiting  bed- 
side nursing,  industrial  nursing,  infant  welfare,  school  nurs- 
ing, tuberculosis  nursing,  social  service  work  and  many  other 
similar  activities,  each  closely  related  to  the  improvement  of 
public  health. 

The  term  pubbc  health  nurse  is  usually  understood  to  mean 
"a  graduate  nurse  who  is  devoting  her  time  and  energies  to 
social  work  aiming  toward  the  improvement  of  the  health  and 
welfare  of  the  public."  Her  training  as  a  nurse  is  essential 
to  the  work  although  actual  bedside  nursing,  as  it  is  ordinarily 
understood,  may  represent  only  a  small  part  of  her  daUy 
duties.  It  is  impossible  to  outline  definitely  all  the  various 
forms  of  work  which  a  public  health  nurse  may  engage  in. 
Indeed  every  year  new  forms  of  social  health  activities  are 
added  to  the  duties  of  the  nurse  under  the  general  heading  of 
**public  health  nursing." 

DEVBLOPMBNT  OP  PUBLIC  HEALTH  NtTESIlfO 

Some  form  of  what  is  now  known  as  public  health  nursing 
has  been  in  existence  for  many  years,  usually  in  connection 
with  the  visitation  of  the  sick  by  nuns,  deaconesses  and  others, 
who  were,  as  a  rule,  almost  always  under  the  control  of  the 

38 


PUBLIC  HEALTH  NUESING  39 

Charch.  It  was  not  until  comparatiYelj  recently,  however,  that 
public  health  nursing,  in  a  form  approaching  the  present,  has 
been  systematically  carried  out.  In  England  there  are  authen- 
tic records  of  visiting  nursing  under  a  centralized  control  as 
early  as  1875,  but  in  America  the  movement  did  not  start  until 
considerably  later  and  in  the  beginning  there  was  little 
attempt  made  to  co-ordinate  the  work,  every  organization  or 
'  municipaliiy  starting  the  work  in  its  own  way  and  according 
to  its  own  ideas  and  ideals. 

During  the  last  twenty  years,  public  health  nursmg  has 
developed  by  leaps  and  bounds  so  that  in  1919  there  were 
nearly  9,000  trained  nurses  who  devoted  their  entire  time 
to  this  iype  of  work.  Some  idea  of  the  growth  of  this  move- 
ment since  1891  may  be  obtained  from  the  following  table: 

OBOWTH  OP  PUBLIC  HEALTH  NUBSINQ  IN  THE  UNITED  STATES* 

Year                      OrgarUzationa  Nurses 

1891 58  130 

1905 200  400 

1914 1992  5152 

1919 3094  8770 

During  the  first  decade  of  this  century,  this  particular  kind 
of  nursing  was  largely  developed  by  local  organizations  which 
were  known  as  district,  or  visiting,  nursing  associations  and 
the  nurses  working  under  such  organization  were  termed 
visiting,  or  district,  nurses.  With  the  growth  of  public  health 
nursing,  however,  the  names  were  outgrown  and  such  associa- 
tions are  now  recognized  as  merdy  special  branches  of  gen- 
eral public  health  nursing. 

NATIONAL  OBOANIZATION  FOB  PUBLIC  HEALTH  NUBSING 

As  the  result  of  the  very  evident  need  for  some  centralized 

body  which  might  speak  with  authority  on  subjects  having  to 

do  with  public  health  nursing,  the  National  Organization  for 

•Statlirtlcal   Department,    National   Organization   for   Fnbllc   Healtk 


40        THE  COMMUNITY  HEALTH  PBOBLEM 

Public  Health  Nursing  was  formed  in  June,  1912,  This 
organization  does  not  undertake  actual  administratiTe  work 
but  acts  as  an  advisory  body,  collecting  and  disseminating 
information,  maintaining  standards,  and  stimulating  new 
endeavor.  The  objects  of  this  association  as  stated  in  a  cir« 
cular  sent  out  from  the  central  office  are:  **to  stimulate  the 
extension  of  public  health  nursing  and  eventually  to  main- 
tain service  bureaus  employing  a  staff  of  secretaries  whose 
services  are  available  to  both  private  and  public  agencies  doing 
public  health  nursing  work.**  A  magazine  **The  Public 
Health  Nurse"  is  published  monthly. 

BED  OBOSS  PUBLIO  HEALTH  NUBSIKQ 

Before  the  war  the  American  Bed  Cross  had  adopted  a 
comprehensive  plan  for  the  development  of  public  health  nurs- 
ing especially  in  rural  districts.  While  this  program  was  some- 
what interfered  with,  because  of  the  shortage  of  nurses  during 
the  war  period,  the  Bed  Cross  has  adopted  a  peace-time  pro- 
gram which  includes  the  extension  of  public  health  nursing 
into  local  communities.  Local  initiative  and  control  is  en- 
couraged under  the  Bed  Cross  plan  but  a  certain  amount  of 
general  supervision  and  guidance  is  retained  by  Division  and 
National  Headquarters. 

TEAnmra 

While  it  is  essential  that  the  public  health  nurse  be  a  trained 
nurse,  in  the  sense  that  she  has  completed  her  hospital  train- 
ing, it  is  also  required  that  she  be  especially  trained  in  the 
public  health  aspects  of  her  work.  Thia  may  be  accomplished 
at  the  present  time  by  special  field  work  in  connection  with 
her  hospital  training  or  by  post-graduate  studies  either  at  a 
college  or  in  connection  with  one  of  the  existing  district  nurs- 
ing associations.  A  few  excellent  nurses  have  received  their 
'  training  in  this  phase  of  nursing  through  practical  work  in 
the  field  under  the  instruction  of  a  trained  supervisor,  but  in 
general  sudi  training  is  inferior  to  the  combined  theoretical 


PUBLIC  HEALTH  NUBSING  41 

and  practical  trainmg  courses  offered  by  colleges  and  schools 
for  public  health  nursing. 

Many  of  the  representative  colleges  offer  courses  leading  to 
a  certificate  in  public  health  nursing.  Teachers  College, 
Columbia  University,  offers  a  full  yearns  course  consisting  of 
eight  months*  work  in  the  college  and  four  months*  training  at 
the  Henry  Street  Settlement,  as  well  as  several  shorter  courses 
which  do  not,  however,  qualify  for  a  certificate.  Undergradu- 
ate nurses  from  approved  hospitals  who  are  taking  the  train- 
ing course  at  the  Henry  Street  Settlement  may  be  admitted 
to  special  classes.  Similar  courses  are  offered  at  the  Uni- 
versity of  Michigan,  the  University  of  Pennsylvania,  the 
University  of  California,  and  Western  Beserve  University. 

It  thus  becomes  evident  that  there  is  a  steady  movement 
to  increase  the  requirements  while  at  the  same  time  the  work 
is  being  constantly  extended.  It  is  pointed  out  that  while  in- 
the  hospital  the  nurse  learns  to  care  for  the  sick,  she  usually 
has  little  experience  in  the  solution  of  either  family  or  com- 
muniiy  problems  which,  in  many  cases,  constitutes  a  large 
part  of  the  work  of  the  public  health  nurse.  The  present 
shortage  of  public  health  nurses  has  caused  a  few  to  protest 
against  what  they  consider  to  be  "over-training*'  but  among 
those  who  may  be  expected  to  speak  with  authority  in  public 
health  circles  a  short  period  of  special  training  is  considered 
not  only  desirable  but  absolutely  necessary.  Indeed  the  state- 
ment is  frequently  made  that,  in  this  field,  a  nurse  without 
special  training  is  worse  than  none. 

If  we  remember  that  the  first  district  nurses  limited  their 
werk  almost  entirely  to  bedside  care,  and  if  we  stop  for  a 
moment  and  consider  the  problems  which  must  have  con- 
fronted such  nurses,  we  may  possibly  appreciate  more  clearly 
the  necessity  for  special  training  in  public  health  nursing. 
The  early  district  nurses  sent  out  to  give  medical  care  only. 
Boon  discovered  that  the  giving  of  medicine  had  little  effect 
if  there  were  no  food  in  the  house;  learned  that  to  secure 
cleanliness  required  more  than  an  order  from  the  physician 
or  nurse ;  and  that  medical  treatment  and  preventive  measniea 


42        THE  COMMUNITY  HEALTH  PBOBLEM 

reqaiied  not  only  musing  skill  bnt  an  imTtipno^  amount  of 
tact  and  social  understanding.  She  soon  found  that  she  was 
making  a  certain  number  of  visits  which  were  entirelj  social 
in  character  and  that  in  order  to  improve  the  health  of  a  par- 
ticular patient  her  work  might  require  a  knowledge  of  eccv 
nomic,  financial,  industrial  or  social  conditions,  which  carried 
her  a  long  way  from  the  therapeutic  principles  she  had  learned 
in  the  hoepitaL 

XHS  BELATION  OF  THS  YIBITIKa  KUBBE  TO  THE  FHTSIOIAS' 

Bedside  nursing,  as  such,  should  always  be  carried  out 
under  the  direction  of  a  physician.  The  public  health  nurse 
who  has  the  welfare  of  the  patient  at  heart  will  always  insist 
that,  if  possible,  a  physician  be  secured  to  prescribe  for  every 
individual  who  appears  ill,  the  nurse  devoting  her  efforts  to 
the  training  of  the  patient,  or  attendants,  in  simple  measures 
for  carxying  out  the  instructions  of  the  attending  physician. 

It  would  seem  that  this  service  might  be  considered  as 
interference  with  the  work  of  the  ph3rsician,  and  in  certain 
isolated  instances  it  has  been  so  considered  but,  in  the  main, 
physicians  have  appreciated  the  help  and  co-operation  of  tiie 
district  nurse  and  have  not  hesitated  to  say  so.  Mary  Sewall 
Gardner*  states  the  attitude  of  the  medical  profession  to 
visiting  nursing  as  follows:  '"The  finer  and  more  broad- 
minded  physician  has  always  recognized  the  public  health 
nurse  as  a  helpmeet  who  strengthens  his  hands  and  helps  him 
to  produce  results  impossible  alone.  The  poorer  and  narrow- 
minded  members  of  the  profession  have  regarded  her  with 
suspicion  and  feared  her  interference  at  every  turn.  Men 
whose  minds  have  been  steadily  fixed  on  the  welfare  of  the 
people,  not  on  circumstances  affecting  themselves,  have  from 
the  fint  gladly  given  to  the  nurse  a  helping  hand  and  with 
a  fine  loyalty  sought  to  strengthen  her  position  with  the 
patients.  Men  occupied  chiefly  with  thdr  own  personal  careers, 
who  have  teaied  that  the  public  health  nurse  might  jeopardize 
either  their  authority  or  the  amount  of  their  work,  have  per- 
•Gudntr.  Uur  Btmtm   PnbUe  KMlth  NnnlBf,  p.  4S,  H«w  York.  1914 


PUBLIC  HEALTH  NUESING  43 

sifltently  denied  her  the  loyally  which  they  so  rigorously 
demanded  for  themselves/' 

In  any  community  which  contemplates  the  establishment  of 
a  district  nnrsing  service  there  is  apt  to  be  a  certain  amount 
of  antagonism  among  the  local  physicians.  This  can  be 
greatly  diminished  if  the  service  is  started  with  the  co-opera> 
tion  of  the  profession  and  if  the  nurses  make  special  efforts 
to  observe  the  ordinary  rules  of  professional  ethics.  These 
rules,  simply  stated,  mean  merely  that  the  physician  and  not 
the  nurse  is  in  charge  of  the  case  and  that  the  nurse  must 
not  take  upon  herself  the  duties  and  responsibilities  rightly 
belonging  to  the  physician. 

Miss  Gardner  interprets  the  rules  of  professional  ethics  to 
mean,  "that  she  (the  public  health  nurse)  should  not  diagnose, 
should  not  prescribe,  should  not  recommend  a  particular  doc> 
tor  or  a  change  of  doctors,  should  not  suggest  a  hospital  to  a 
patient  without  the  concurrence  of  the  doctor  and  should 
never  criticize,  by  word  or  unspoken  action,  any  member  of 
the  medical  prpofession."  These  rules  appear  to  me  too 
severe  and  I  believe  that  in  time  they  may  be  modified  so 
that  a  nurse  will  not  be  compelled  to  serve  xmder  a  physician 
who  is  palpably  ignorant  or  dangerously  careless.  In  such 
cases  the  nurse  should  report  to  her  immediate  superior  who, 
if  she  is  experienced  and  resourceful,  can  usually  find  a  way 
out  of  the  difficully. 

BPE0IALIZATI017  IK  PUBLIO  HEALTH  WBBUIQ 

The  anti-tuberculosis  campaign  required  nurses  of  spedal 
training  and  with  a  special  knowledge  of  the  care  and  man- 
agement of  the  tuberculous,  so  that  there  gradually  developed 
nurses  who  were  specialists  in  this  work.  About  the  same  time 
there  was  an  extension  of  school  nursing  so  that  in  this  field 
there  were  also  nurses  who  by  virtue  of  their  training  had 
become  specialists.  In  the  same  manner  various  other  branches 
of  medicine  and  a  variety  of  social  welfare  movements  led  to  a 
number  of  other  specialties  so  that  at  one  time  it  is  said  to  have 


44        THE^  COMMUNITY  HEALTH  PROBLEM 

been  difScult  to  find  a  nurse  who  was  doing  ordinary  bedside 
nursing.  It  has  been  felt  by  some  that  so  mnch  spedalization 
is  undesirable  because  it  tends  to  narrow  the  field  of  vision  tnd 
interferes  with  the  l»oad  grasp  of  the  public  healtii  pn^em 
as  a  whole. 

While  specialists  are  certain  to  remain  and  while  they, 
without  doubt,  fill  a  distinct  place  in  the  public  health  pro- 
gram the  tendency  of  the  recent  graduate  to  specialize  should 
be  discouraged.  It  is  far  better  to  limit  the  work  to  certain 
physical  boundaries,  such  as  a  group  of  city  blocks,  or  a  rural 
township,  than  it  is  to  limit  the  services  according  to  the 
type  of  disease  under  treatment.  The  public  health  nurse 
accomplishes  most  through  personal  contact,  obtaining  ther^y 
the  confidence  of  the  family.  Cases  have  been  reported  where 
as  many  as  five  different  nurses  were  visiting  the  same  family. 
Such  a  procedure  cannot  fail  to  result  in  duplication  of  effort 
and  confusion  and  should  of  course  be  avoided.  In  this  con- 
nection it  is  desired  to  point  out  to  those  doing  health  work 
that  in  dealing  with  patients  it  is  always  much  better  to 
arrange  the  visits  so  that,  in  so  far  as  practicable,  all  instruc- 
tions are  ^ven  by  the  same  person.  It  frequently  happens  that 
inconsequential  variations  in  the  details  of  instructions  given 
by  two  different  nurses  lead  the  patient  to  distrust  them  both. 

Certainly  it  would  appear  best  if  there  are  to  be  specialists 
in  the  field  of  public  health  nursing  that  they  ^ould  be 
limited  in  number  and  that  they  should  devote  their  time 
largely  to  research,  teaching  and  supervision^  rather  than  in 
the  more  intimate  details  of  social  welfare. 

TDBEBCTTLOSIB  ASD  FT7BLI0  HEALTH  inTBSIKa 

Among  the  first  of  the  specialists  in  public  health  nursing 
was  the  tuberculosis  nurse.  It  has  been  stated  that  this  work 
began  in  New  York  about  1902  and  extended  rapidly  in  New 
York  and  to  many  other  cities. 

Tuberculosis  is  a  disease  which  is  peculiarly  adapted  to 
the  work  of  the  public  health  nurse.    It  is  a  chronic  disease. 


i^^ 


PUBLIC  HEALTH  NUBSING  45 

contmnons  treatment  ia  required,  physicians  visits  are  infre- 
quent (nsnally  once  in  two  weeks  or  tiiereabouts),  the  social 
problems  are  nnmerons,  and  the  field  of  prerentlTe  medicine 
is  almost  imlimited. 

In  such  cases  the  nurse  sees  that  the  physician's  orders 
are  carried  out,  aids  in  the  securing  of  sanitarium  treatment 
for  suitable  cases,  does  what  she  can  to  prevent  contact 
infection  and  aids  in  the  economic  rehabilitation  of  the  family. 
She  helps  children  in  tuberculous  families  to  secure  vacations 
in  the  country,  tries  to  influence  the  working  members  of  the 
family  to  secure  suitable  occupations,  insists  on  the  systematic 
routine  medical  care  of  the  patient,  and  teaches  the  home 
attendants  simple  methods  to  prevent  the  spread  of  the 
infection. 

INDUSTBIAL  KUBSIXa 

As  the  term  implies,  industrial  nurses  are  nurses  employed 
by  mercantile  or  manufacturing  establishments  for  the  bene- 
fit of  sick  or  injured  employees.  The  industrial  nurse  is  a 
specialist  but  she  specializes  by  limiting  her  attention  to  the 
employees  of  a  certain  industry  rather  than  in  any  limited 
field  of  medicine.  Her  duties  vary  according  to  the  demands 
made  by  the  particular  industry  concerned  and  the  various 
problems  presented  by  the  sick  or  injured. 

Industrial  nursing  has  been  greatly  stimulated  by  the  intro- 
duction of  the  workmen's  compensation  principle,  although 
many  nurses  were  employed  by  industrial  establishments  be- 
fore this  law  went  into  effect.  The  work  of  course  varies 
greatly  with  the  nature  of  the  business  and  with  the  require- 
ments of  the  employer.  In  some  cases  it  is  limited  to  first  aid 
during  business  hours  at  the  plant  dispensary  and  in  others  a 
complete  visitiiig  nursing  system  available  to  both  employees 
and  their  families  is  carried  out  to  the  last  detail.  The 
Talue  of  the  services  of  the  nurse  in  factory  first  aid  rooms 
has  been  clearly  demonstrated  to  employers  of  a  thousand  or 
more  persons  although  the  need  is  less  evident  to  those  who 


46        THE  COMMUNITY  HEALTH  PROBLEM 

employ  a  smAlIer  number.*  The  need  of  a  nurse  for  the  care 
of  the  sick  and  for  the  prevention  of  disease  is  not,  however, 
80  generally  admitted  among  employers  of  labor.  While  many 
of  the  larger  plants  have  adopted  a  fairly  thorough  health 
service  with  a  public  health  nurse  in  charge,  there  is  still  a 
large  field  in  which  no  effort  is  made  by  the  employer  to 
improve  either  personal  health  or  community  social  condi- 
tions. However  the  industrial  nursing  movement  has  had  a 
remarkable  stimulus  during  the  post-war  period  and  promises 
to  spread  rapidly. 

SCHOOL  NUBSIKO 

With  tibe  development  of  inspections  in  schools  came  tha 
school  nurse.  It  was  found  that  to  accomplish  definite  results 
personal  contact  with  the  parents  and  follow  up  efforts  were 
necessary.  Few  physicians  could  be  found  who  had  the  time 
for  this  work  and  few  teachers  who  had  either  the  time  or  ihe 
required  training,  so  that  school  nurses  were  required  almost 
from  the  first  The  most  striking  result  of  the  introduction 
of  nurses  in  schools  was  the  increased  attendance.  This  was 
brought  about  by  the  fact  that  the  nurses  cut  down  the 
number  of  ezdufflons  from  school  for  minor  easily  curable 
troubles,  such  as  ring  worm,  pediculosis,  etc.  In  the  next 
place  efforts  were  directed  toward  the  cure  of  such  simple 
disMses  as  enlarged  tonsils,  dental  diseases,  and  mild  coughs 
and  colds,  and  more  recently  efforts  have  been  made  to  over- 
come under-nutrition  and  mal-development  in  children  of 
school  age. 

The  school  nurse  is  sometimes  under  the  direction  of  the 
board  of  education  and  sometimes  under  the  healih  authori- 
ties. In  the  broader  sense  of  her  duties  the  nurse  is  largely 
concerned  with  health  education  rather  than  actual  treatment 
so  that  those  who  insist  that  her  duties  are  properly  a  part 
of  the  department  of  education  have  very  strong  arguments. 

*ta  tcaxm  wh«nr»  eonTWDSttfOB  IiWB  tn  In  «lftct,  th«  fusoraBm  eom- 
panlet  recoffnlze  the  Tafne  of  a  first  aid  atation  with  a  nurse  in  rnarK* 
and  mak*  a  reduction  In  tha  Insnranca  rates  to  «mpl07«r8  aooptlsg  tnu 
plan. 


PUBLIC  HEALTH  NUESING  47 

In  many  schools  there  are  classes  in  home  hygiene  and  the 
care  of  the  sick,  dietetics,  and  first  aid,  which  ar»  tanghti  in 
part  at  least,  by  the  school  nurses. 

OTHSB  SPECIALTIES 

There  are  many  other  specialties  which  have  become  part 
of  public  health  nursing.  Among  these  are  child  welfare 
nursing,  maternity  nursing,  pre-natal  nursing,  venereal  disease 
nursing,  mental  hygiene  nursing  and  many  others.  It  will 
foe  noted  that  in  some  cases  the  special  field  talces  its  name  from 
the  special  field  of  medicine  with  which  it  deals  and  in  others 
from  the  name  of  the  establishment  in  which  the  nursing  la 
done,  so  that  it  is  often  difficult  to  say  just  where  one  specialty 
leaves  off  and  another  begins.  Thus  the  school  nurse  does 
bedside  nursing  when  she  visits  a  sick  child  in  his  home  and 
the  industrial  nurse  invades  the  field  of  tuberculosis  nursing 
when  the  disease  occurs  in  an  employee  of  a  particular  estab- 
lishment. 

PUBLIO  HEALTH  KtTBSINa  UNDER  PUBLIC  AUTHOBITT 

State  or  municipal  control  of  public  health  nursing  is 
considered  by  many  as  essential  for  the  wide  and  thorough 
development  of  the  nursing  program.  While  there  has  been 
considerable  opposition  to  ^is  view  the  movement  is  gradually 
spreading  so  tiiat  the  employment  of  nurses  is  now  considered 
an  essential  part  of  every  comprehensive  municipal  health 
program.  Especially  in  schools,  the  employment  of  nurses  has 
become  general  and  is  bound  to  spread  because  the  need  is 
recognized  and,  in  the  end,  it  is  felt  that  the  solution  of  the 
problem  of  child  welfare  is  the  duty  of  tiie  community  rather 
than  of  certain  individuals.  This  being  the  case,  is  not  mxmi- 
cipal  or  state  control  the  most  practicable  method  which  we 
have  to  accomplish  tangible  and  permanent  results  by  means 
of  community  effort? 

In  some  cities  tuberculosis  nursing  has  been  taken  over 
either  wholly  or  in  part  by  the  local  health  department  and 


48        THE  COMMUNITY  HEALTH  PBOBLEM 

in  other  localities  bedside  nniBiiig  has  been  placed  nnder  the 
same  contioL  In  New  York  Citj  aa  in  many  other  places, 
during  the  influenza  epidemic  of  1920  large  numbers  of  vol- 
unteer nnrses  were  employed  by  the  City  Department  of 
Health  in  the  effort  to  control  the  epidemic. 

It  is  plainly  apparent  that  there  is  a  strong  tendency  for 
the  state  or  municipal  health  authorities  to  take  over  certain 
parts,  at  least,  of  the  public  health  nursing  program,  and  in 
some  localities  this  has  been  opposed  on  the  ground  that 
the  work  was  better  done  under  private  controL 

However,  those  who  fear  that  the  loss  of  control  by  private 
enterprise  will  result  in  a  deterioration  of  the  service  need 
not  r^et  the  change,  for  the  entire  health  program  is  so  large 
that  private  enterprise  may  be  successfully  utilized  to  its 
fullest  extent  in  other  fields  if  it  can  be  relieved,  in  part  at 
least,  of  the  load  it  is  now  carrying.  Every  health  movement  is 
of  necessity  largely  limited  aa  to  available  funds  and  the 
broad  application  of  any  welfare  movement  can  only  take  place 
through  the  movement  becoming  part  of  the  local  or  state 
government. 

THE  FUBLIO  HEALTH  NUBSS  IN  THE  OOlOCUmTT 

It  is  a  generally  accepted  principle  that  organizations  em- 
ploying public  health  nurses  should  be  non-sectarian;  that 
association  with  a  church  even  to  the  extent  of  having  offices 
in  the  church,  or  parish  house,  tends  to  prevent  the  fullest 
utilization  of  the  nurses'  services.  For  self-evident  reasons 
the  nurse  should  never  interfere  with  the  religious  views  of  her 
patients.  Churches  may  contribute  to  the  support  of  the 
nursing  association  which  should  in  turn  care  for  the  entire 
community  without  sectarian  limitation. 

Limitation  of  the  nurses'  services  to  a  certain  prescribed 
district  is  not  open  to  the  same  objection.  Indeed,  in  spite 
of  arguments  which  have  been  advanced  to  the  contrary,  the 
writer  believes  that  in  practically  every  case  the  district  cov- 
ered by  the  nurse  should  be  definitely  limited  in  extent.    Occa- 


y^ 


PUBLIC  HEALTH  NURSING  49 

sionally  the  work  of  visiting  nurses  has  been  greatly  inter- 
fered with  becanse  of  the  enormous  districts  which  must  be 
covered,  in  some  cases  so  great  that  not  more  than  three  or 
four  calls  could  be  made  in  the  course  of  the  day's  work. 
The  value  of  the  services' of  a  public  health  nurse  lies,  in  part 
at  least,  in  her  abUiiy  to  supply  medical  supervision  at  a  rea< 
sonable  cost  and  this  element  of  cost  is  greatly  increased  when 
a  long  trip  is  made  to  see  a  single  patient. 

Before  the  war  the  services  of  a  public  health  nurse  were 
figured  at  from  fifty  to  seventy  cents  per  visit.  "With  the 
increase  in  salaries  and  the  cost  of  supplies  the  figure  today 
is  increased  possibly  to  the  neighborhood  of  seventy-five  cents, 
or  more,  for  each  visit.  If  the  districts  are  unlimited  in  area 
the  cost  may  increase  alarmingly. 

Of  course  the  geographical  boundary  shoidd  be  based  on  the 
population  which  might  be  expected  to  require  the  nurses' 
services.  The  nature  of  the  nurses*  work  and  the  ability  of 
inhabitants  of  a  given  district  to  employ  private  nurses,  both 
80  greatly  influence  the  population  which  may  be  satisfac- 
torily served  by  a  single  nurse  that  one  hesitates  to  give  exact 
figures.  It  may  be  safely  said,  however,  that  in  a  community 
of  3,000  inhabitants  representing  aU  classes  there  wiU  be 
found  sufficient  work  to  require  the  full  time  of  a  public 
health  nurse.  In  rural  districts  this  number  would  probably 
be  smaller. 

The  question  of  payment  is  rather  a  vexatious  one.  It  is 
ordinarily  the  custom  to  charge  a  fixed  fee  to  patients  able 
to  pay — ^usually  fifty  cents  or  thereabouts — scaling  the  fee 
down  for  those  less  able,  in  some  cases  to  as  low  as  five  cents, 
eventually  treating  some  cases  for  nothing.  The  arguments 
advanced  in  favor  of  this  plan  are  that  it  avoids  the  idea  of 
charily  to  which  most  people  object,  and  helps  pay  the 
nurses'  expenses.  Others  claim  that,  like  education,  the 
nurses'  services  should  be  free  to  alL  Possibly  the  middle 
ground  is  best,  the  nurse  giving  h^r  services  when  she  is 
paid  by  the  state  or  municipality  and  receiving  a  fee  when  she 
is  supported  by  private  organizations.   Of  course,  in  industrial 


^: 


60        THE  COMMUNITY  HEALTH  PEOBLEM 

or  insxiTaiice  nursing,  snfficient  fees  should  be  charged  to 
ooTer  not  only  the  muses'  time  but  oyerhead  expenses  as  well, 
bnt  such  fees  should  be  paid  by  the  employer  or  insurance 
company,  rarely,  if  ever,  by  the  patient. 

THB  HEXBY  STREET  SETTLEMENT 

Of  interest  because  it  represents  a  large  and  interesting 
visiting  nursing  association,  the  Henry  Street  Settlement  may 
profitably  be  discussed  in  some  detail.  Started  twenty-sis 
years  ago  by  two  nurses  it  has  expanded  its  actirities  so  that 
at  present  nearly  two  hundred  nurses  are  employed  in  the 
work  and  during  a  single  year  43,946  patients  were  cared  for. 

The  service  was  started  in  the  Henry  Street  district,  one  of 
the  poorer  sections  of  New  York  City  in  which  the  inhabi- 
tants are  almost  all  of  foreign  birth.  It  increased  so  rapidly 
that,  in  1919,  there  were  in  operation  twelve  district  branches 
throughout  the  city  at  each  of  which  there  were  a  supervisor 
and  two  or  more  nurses.  The  service,  in  the  main,  consists  of 
general  bedside  nursing  and  it  is  given  chiefly  to  those  who 
are  unable  because  of  economic  circumstances  to  provide  ade- 
quate attention  for  their  families  in  time  of  illness. 

The  expenses  of  the  organization  are  met  by  small  fees  paid 
by  those  treated,  by  payment  for  services  rendered  to  em- 
ployees of  industrial  corporations  and  policy  holders  of  insur- 
ance companies,  and  by  voluntary  contributions. 

During  the  epidemic  of  influenza  in  1920  a  total  of  30,555 
visits  were  made  between  January  twenty-fourth  and  Feb- 
ruary eighteenth.  Many  cases  of  pneumonia  received  nursing 
care  in  their  homes  with  a  mortality  which,  it  is  claimed, 
was  considerably  less  than  that  of  the  city  hospitals.  A  large 
proportion  of  the  patients  are  children,  the  result  being  that 
no  small  part  of  the  nurses'  work  is  devoted  to  education  of 
the  mother  in  simple  rules  for  the  improvement  of  the  health 
and  welfare  of  the  small  sufferers.  A  maternity  center  is 
established  in  one  district  which  in  a  single  year  had  a  record 
of  28,982  visits  to  mothers  and  babies.*  As  a  result  of  this 

•Vtom  gtatlBtlefl  farnlBhcd  by  the  Henry  Street  Settlement. 


PUBLIC  HEALTH  NURSING  51 

intensive  work  it  was  felt  that  infant  mortality  was  dlBtinctly 
diminiihed. 


INSUBAl^CE  NTTBSINO 

Closely  related  to  industrial  nursing  is  the  program  insti- 
tnted  by  the  Metropolitan  Life  Insurance  Company  for  its 
industrial  policy  holders. 

This  service  was  started  in  1909  in  conjunction  with  the 
Henry  Street  Settlement,  Department  of  Nxirsing,  in  New 
York  City,  and  is  limited  entirely  to  industrial  policy  holders; 
that  is  those  holding  life  insurance  for  small  amounts,  most 
of  whom  are  persons  employed  in  industrial  occupations. 
The  service  increased  rapidly  in  New  York  and  soon  spread 
to  other  cities  so  that  today  it  may  be  said  to  be  applied  nni- 
versally  by  this  company  to  all  industrial  policy  holders  who 
are  ill  and  require  bedside  treatment.  In  some  cases,  in  cities 
outside  of  the  New  York  City  area,  visits  are  made  by  com- 
pany nurses  but  as  a  rule  it  employs  the  nurses  of  the  local 
visiting  nurses'  association.  The  total  cost  for  the  service  to 
the  company  during  the  year  1918  was  $810,387.86  and  the 
average  cost  per  visit  was  52.5  cents.* 

The  average  number  of  visits  per  patient  was  4.9.  Based 
upon  the  entire  number  of  industrial  policies  in  force  the 
cost  per  policy  was  4.6  cents. 

The  Metropolitan  Company  have  prepared  a  table  showing 
the  influence  of  the  nursing  service  and  other  welfare  activi- 
ties upon  the  mortality  rate. 

*FmikeI,  Le«  K. :  The  Welfare  Work  of  the  Metropolitan  Life  lamt- 
ance  Company  for  Its  Indastrlal  Policy  holders.    Beport  for  1918^ 


62        THE  COMMUNITY  HEALTH  PEOBLEM 

INDUSIBIAL  EZPEBIZKOZ^  MBTBOPOLHAK  LZTS  IKBUBAHGB  00. 

1911-1917 

Deaths  per  1,000 

PereetU, 

Age  Period  1917  1911  Decline 

All  ages 11.6 12.5 7Ji 

1  to  4 10.6 12.8 18.0 

1    20.4 25.2 19.1 

2   13.5 16.6 18.7 

3   7.7 9.3 17.2 

4   6.6 6.6 15.2 

5to9 3.4 2.7 3.7 

10  to  14 2.6 2.7 3.7 

15  to  19 4.8 4.7 *2.1 

20  to  24 6.6 7.3 9.6 

25  to  34 8.4 9.5 11.6 

35  to  44 12.4 13.7 9.5 

45  to  54  . .  .■ 19.6 19.8 1.0 

65  to  64 35.8 36.0 .6 

65  to  74 76.4 74.5 *2.6 

74  and  over 142.6 139.3 ♦2.4 

*P«r  Cent  IncreaM  In  seven  yean. 

There  ia  shown  by  the  abore  table,  for  all  ages,  a  decline 
of  the  mortality  rate  of  over  7  per  cent  in  seven  years.  The 
decline  is  most  marked  and  most  significant  during  the 
early  years,  being  over  19  per  cent,  for  the  first  year  of  life. 
When  the  rates  for  the  principal  canses  of  death  of  policy 
holders  are  compared  with  general  death  rates  for  the  com- 
munity at  large  as  obtained  from  government  sources,  the 
results  are  distinctly  in  favor  of  the  policy  holders.  It  is 
fair  to  assume  that  a  part  of  the  decline  in  mortality,  and 
improvement  in  general  health,  was  due  to  the  program  of 
visiting  nursing  established  in  1909. 

EFFlftjT  OF  THE  YISITINa  NIJSSE  ON  PT7BLI0  HEALTH 

It  has  been  pointed  out  that  approximately  only  one-tenth 
of  all  illness  is  treated  in  the  hospital,  the  remainder  being 


PUBLIC  HEALTH  NUBSING  53 

cared  for  in  the  patient's  home.  Consequently  in  order  to 
reach  every  sick  individual,  nine-tenths  of  the  side  must 
receive  medical  care  in  the  home.  Such  visits  may  be  made 
either  by  physicians  or  public  health  nurses  or  by  both.  In 
acute  ilhiess,  and  to  diagnose  disease  and  outline  treatment, 
the  services  of  a  physician  cannot  be  dispensed  with,  but  for 
the  routine  care  of  chronic  illness  and  for  prevention  of 
disease  there  is  at  present  no  one  better  qualified  than  the 
public  health  nurse. 

The  medical  problems  connected  with  the  supervision  of 
health  within  the  limits  of  the  home  are,  frequently,  compara- 
tively insignificant;  but  the  social  and  economic  problems 
which  must  be  solved  in  every  home,  before  the  greatest  benefit 
may  be  secured  through  the  application  of  the  lessons  learned 
from  recent  advances  in  the  field  of  preventive  medicine,  are 
such  that  the  services  of  a  trained  public  health  nurse  are 
almost  essential.  This  is  especially  true  among  the  poorer 
classes. 

If  there  has  been  one  single  factor  more  than  another  which 
has  made  for  general  improvement  in  health  conditions  in 
the  larger  cities  during  the  last  quarter  century,  that  factor 
is  without  doubt  the  rapid  spread  of  public  health  nursing. 
Actual  services  during  illness  represent  only  a  small  part  of 
the  nurses'  work.  Education  of  the  bedside  attendants  in 
proper  methods  of  caring  for  the  sick,  education  of  the 
patients  as  to  the  necessity  of  early  treatment,  and  education 
of  the  public  as  to  the  importance  of  cleanliness  and  sanita- 
tation  are  all  considered  a  part  of  her  duties.  It  is  the  general 
concensus  of  opinion  that  no  program  for  the  betterment  of 
community  health  will  be  satisfactory  unless  the  public  nurse 
plays  a  major  part  in  its  execution. 


CHAPTEB  yi 
THE  CAMPAIGN  FOR  BBTTBR  HEALTH 

In.  outlining  a  plan  for  the  improyement  of  commnniiy 
health  it  is  necessary  to  consider  the  problem  as  a  whole  and 
outline  a  plan  of  action  much  as  a  general  plans  his  action 
against  an  enemy  force.  The  information  which  is  gained 
from  health  surveys,  from  vital  statistics,  and  from  com« 
munity  records,  corresponds  to  the  army  officer's  map  of  the 
terrain;  the  methods  and  practice  of  modern  8cienti£c  med- 
icine are  in  a  sense,  the  ammunition  to  be  used ;  the  co-opera- 
tion of  the  citizens,  physicians,  civil  authorities  and  workers 
is  represented  by  the  morale  of  the  troops;  and  the  success 
of  the  campaign  depends  upon  the  intelligent  use  of  all  these 
factors  by  a  keen  administrator. 

Back  of  the  battle  lines  there  must  be  a  dependable  source 
of  supply,  and  in  the  same  manner  back  of  every  commimity 
health  effort  there  must  be  adequate  and  available  funds  sup- 
plied either  by  public  authority  or  private  individuals.  Un- 
limited funds  are  practically  never  available  and  it  conse- 
quently becomes  the  duiy  of  the  administration  to  accomplish 
the  greatest  possible  result  with  the  least  practicable  expen- 
diture. 

HEALTH  ADMINISTRATION 

If  there  is  one  element  more  important  than  another  in  the 
solution  of  the  community  health  problem  it  is  the  question 
of  administration.  Enormous  amounts  have  been  spent  for 
the  benefit  of  public  health  which  have  been  wasted  because 
the  funds  have  been  poorly  administered.  Health  administra- 
tion includes  not  only  the  expenditure  of  money  but  the  con- 
trol of  executives  as  welL  It  should  work  for  co-operation  and 

54 


CAMPAIGN  FOB  BETTER  HEALTH     55 

team  work  of  all  existing  health  agencies  and  should  aim  to 
encourage  the  interest  and  enthusiasm  of  the  citizens  of  the 
community. 

There  are  several  different  forms  of  control  of  health  ad- 
ministration. It  may  be  under  the  control  of  the  state,  as 
would  be  expected  under  a  purely  socialistic  or  paternalistic 
form  of  government.  Of  this  form  there  is  considerable  to  bo 
said  in  favor  and  comparatively  little  against.  From  a  health 
viewpoint  a  paternalistic  form  of  government  can  jiccomplish 
wonders.  "While  sanitary  defects  cannot  be  corrected  by  de- 
cree they  can  be  greatly  discouraged  by  laws  creating  mod- 
erately severe  fines  for  offences  against  sanitation.  Improve- 
ment of  health  conditions  under  military  authority  which  is, 
in  its  essence,  paternalistic,  has  been  sufficiently  well  demon- 
strated (for  example  the  elimination  of  typhoid  fever  during 
the  recent  war)  to  indicate  the  wide  range  of  its  possibili- 
ties. Complete  socialistic  health  control  will  probably  never 
occur  in  America  and  there  is  some  doubt  as  to  its  success 
even  if  it  should  occur,  but  a  certain  measure  of  socialistic 
control — ^using  the  term  in  its  broadest  sense —  is  inevitable. 
Indeed  our  present  state  health  departments  are  in  a  sense 
socialistic  forms  of  governmental  control. 

The  second  alternative  is  the  administration  of  health  ac- 
tivities by  a  private  organization  such  as  the  Eockefeller 
Foundation,  the  Bed  Cross,  or  one  of  the  various  other  wel- 
fare organizations  which  are  working  for  better  community 
health.  The  disadvantage  of  private  control  is  that  there  are 
usually  insufficient  funds  to  reach  more  than  a  small  part  of 
the  population  so  that  financial  aid  furnished  by  such  organi- 
zations must  be  devoted  to  only  a  few  localities  where  experi- 
ments may  be  made  and  the  results  demonstrated  to  the  coun- 
try as  a  whole. 

The  third  plan  of  administration  presupposes  the  control  by 
the  community  itself  through  representatives  fleeted  by  its 
citizens.  It  is  this  plan  which  is  being  studied  in  Cincinnati 
by  the  National  Social  Unit  Organization.  The  difficulty  asso- 
ciated with  such  a  plan  is  that  members  of  ihe  community 


56        THE  COMMUNITY  HEALTH  PEOBLEM 

rarely  haye  sufficient  broadness  of  vision  and  experience  €o 
visnalize  the  results  of  better  health  and  that  from  a  practical 
standpoint,  communities  up  to  the  present  have  not  made  full 
use  of  preventive  medicine  as  it  exists. 

As  8  matter  of  fact  all  these  forms  of  administration  are 
being  used  today.  It  is  probable  that  the  state  will  take  the 
initiative  in  health  matters  and  that  in  the  end  they  will  be 
administered  largely  by  local  authorities  under  the  control 
of  the  state  or  federal  government.  Private  funds  should  be, 
and  are.  used  to  direct  research  and  to  demonstrate  the  value 
of  remedies  and  preventive  measures.  Their  influence  will  be 
felt  in  concentrating  the  attention  of  the  community  on  cer- 
tain conditions  such  as  infant  welfare,  pre-natal  care,  or 
other  similar  conditions,  which  might  otherwise  be  overlooked. 

It  matters  not  from  whence  the  administration  derives  its 
powers,  it  must  work  with  the  people,  not  at  them.  It  must 
have  the  good  will  of  its  executives  and  must,  by  unceasing 
efEorl^  secure  and  keep  the  sympathy  and  understanding  of 
the  people  or  the  full  me^ure  of  success  will  not  be  attained. 

FBEVENTION  OF  ACCIDENT  AND  DISEASE 

Health  work  should  start  with  prevention.  "WTiilc  the  im- 
portance of  preventive  medicine  is  well  recognized  by  modem 
medical  science  it  is  difficult  for  public  health  authorities  to 
secure  adequate  appropriations  for  prevention  of  disease.  The 
effects  of  measures  for  prevention  are  not  always  plainly  seen 
and  consequently  not  appreciated.  Often  it  takes  the  scourgd 
of  a  widespread  epidemic  before  appropriate  measures  for  the 
prevention  of  such  diseases  as  typhoid  fever  and  yellow  fever 
are  instituted.  The  cost  of  good  water,  and  of  efficient  sewage 
disposal  are  high  but  not  nearly  so  high  as  the  costs  of  those 
diseases  caused  by  the  neglect  of  well-recognized  sanitary  re- 
quirements. This  is  well  known,  yet  comparatively  few  com- 
munities have  appropriated  sufficient  funds  to  wipe  out  entirely 
typhoid  and  diarrh^  diseases,  which  are  largely  carried  by  a 
polluted  water  supply. 


r> 


CAMPAIGN  FOB  BETTER  HEALTH  67 

PreYentive  measnres  include  the  prevention  of  accidents. 
The  enactment  of  workmen's  compensation  laws  has  done 
more  than  any  other  on©  thing  to  promote  the  "Safely 
First**  movement-  These  laws  place  the  cost  of  injnry 
directly  upon  the  industry  concerned  so  that  it  is  to  the 
financial  advantage  of  the  employer  to  prevent  as  many  acci« 
dents  as  possible.  As  a  consequence  of  these  laws  many  devices 
have  been  installed  to  prevent  accidents,  and  strict  rules 
adopted  to  prevent  employees  from  "taking  chances."  It  is 
rather  an  odd  commentary  on  the  operation  of  the  human 
mind  that  men  will  avoid  danger  because  of  a  factory  rule  and 
fear  of  losing  their  jobs  when  they  will  not  avoid  the  same 
danger  for  fear  of  loss  of  life  or  limb. 

Statistics  show  a  rapidly  increasing  number  of  street  acci- 
dents, especially  those  due  to  automobiles.  The  community 
can  do  much  to  decrease  the  number  of  such  accidents  both 
by  carefully  considered  laws,  and  publicity  widely  dissemi- 
nated so  as  to  direct  the  attention  of  the  public,  both  drivers 
of  machines  .and  pedestrians,  to  the  extent  of  the  dangers 
which  exist. 

Industrial  diseases,  such  as  lead  and  arsenic  poisoning, 
should  be  reduced  to  a  minimum.  SufScient  testimony  is  at 
hand  to  indicate  a  method  of  preventing  nearly  every  form 
of  industrial  disease.  Education  of  the  public  and  the  inclu- 
sion of  such  diseases  under  the  provisions  of  compensation 
laws  should  be  the  first  moves  for  prevention. 

Diseases  spread  by  social  contact — and  I  use  the  term  in 
its  broadest  sense — are  much  more  difficult  to  deal  with  than 
are  either  industrial  diseases  or  those  due  to  gross  sanitary 
defects.  People  resent  any  attempt  to  control  their  health  by 
taking  away  anything  which  may  be  considered  liberty  of 
action.  The  enactment  of  prohibition  wiU.  no  doubt  prevent 
many  diseases,  but  it  is  looked  upon  as  an  affront  to  personal 
liberty.  Venereal  diseases  are  spread  broadcast  in  nearly  every 
community,  but  efforts  to  prevent  their  spread  are  met  with 
opposition.  Contagious  diseases  are  often  disseminated  b«- 
tause  it  is  hard  to  make  people  observe  rules  of  quarantine. 


58        THE  COMMUNITY  HEALTH  IPHOBLEM 

The  danger  of  the  public  drinkiiig  cap  has  long  been  recog* 
nized  but  it  required  years  of  education  and  the  passage  of 
state  laws  before  it  was  discarded. 

Two  special  measures  are  at  our  disposal  to  combat  the 
spread  of  disease  caused  by  social  contact:  1,  Education, 
which  is  slow  but  accomplishes  results  if  persistently  carried 
out.  2,  Legislation,  which  must  be  carefully  planned,  and 
enacted  only  after  a  period  of  education. 

OUBATIVB  TBEATHEKT  OF  INJUBY  AND  DI8SASB 

In  every  community  the  question  should  be  asked,  *T)o 
the  citizens  of  this  community  receive  adequate  medical  care?" 
The  establishment  of  a  modem  hospital,  the  location  of  ex- 
cellent physicians  in  the  community  and  the  expenditure  of 
money  for  poor  relief  do  not  necessarily  constitute  adequate 
community  treatment.  Investigations  must  be  made  to  deter- 
mine whether  the  money  is  spent  to  the  best  advantage  and 
whether  local  conditions  either  in  reference  to  physicians  or 
to  hospital  service  are  such  as  to  interfere  with  the  best  type 
of  service. 

'  Frequently  a  community  will  be  found  where  there  are  a 
numb^  of  excellent  physicians  but  no  facilities  for  laboratory 
or  x-ray  work,  thus  seriously  crippling  the  medical  service. 
Again  where  there  may  be  no  nursing  service,  phvsicians  being 
obliged  to  devote  a  large  part  of  their  time  to  this  work  which 
could  be  done  better  and  at  less  cost  by  a  visiting  nurse. 

There  is  a  certain  amount  of  lost  energy  in  private  prao* 
tice.  Physicians  do  not  limit  the  area  in  which  they  work 
but  spend  much  of  their  time  traveling  from  patient  to 
patient,  causing  thereby  a  certain  amount  of  duplication  of 
effort  This  is  due  largely  to  the  personal  equation,  it  being 
regarded  as  the  right  and  privilege  of  any  sick  person  to 
choose  his  own  physician.  Thus  Doctor  A.  drives  ten  miles 
to  see  a  patient  who  lives  next  door  to  Doctor  B.  While  at 
the  same  time  Doctor  B.  may  travel  the  same  distance  to  see 
his  patient  who  lives  near  Doctor  A.  This  represents  an  enor- 


CAMPAIGN  FOE  BETTEE  HEALTH     59 

mons  waste  of  time  and  energy  but  this  right  of  free  choice 
is  zealously  gnarded  by  the  medical  profession,  and  demanded 
by  the  public.  It  is  believed  that  this  demand  for  free  choice 
is  not  as  important  as  it  appears  to  be  and  that  if  physicians 
would  agree  to  co-operate,  working  together  for  the  pubUo 
good,  much  of  this  duplication  of  effort  could  be  eliminated. 
It  is  certain  that  under  the  present  system  physicians  have 
little  time  to  devote  to  preventive  medicine  or  public  health. 

Much  wasted  energy  could  be  avoided  and  a  considerable 
saving  of  the  physician's  time  accomplished  by  a  wider  use 
of  the  visiting  nurse  in  private  practice. 

The  importance  of  the  visiting  nurse  In  the  cure  of  disease 
cannot  be  overestimated.  It  has  been  stated  that  over  90  per 
cent,  of  illness  occurs  in  the  home  and  must  be  treated  there. 
It  is  in  such  cases  that  the  visiting  nurse  finds  her  work. 
Her  services  should  be  made  available  for  rich  and  poor  alike, 
and  above  all  her  work  should  be  limited  to  certain  well- 
defined  areas  from  the  start  so  that  duplication  of  effort  may 
be  avoided.  If  the  area  in  which  she  practices  is  Hmited  she 
will  be  able  to  accomplish  much  more  than  if  required  to 
spend  a  large  part  of  her  time  traveling  from  place  to  place. 

BXHABnJTATIOK 

After  the  storm  the  salvage  of  wreckage  must  begin.  After 
injury  or  disease  there  is  nearly  always  a  more  or  less  pro- 
longed period  of  partial  disability  which  calls  for  rehabilita- 
tion. In  the  mildest  cases,  disability  can  be  overcome  by  a  few 
weeks'  trip  to  the  country  or  a  short  stay  in  a  convalescent 
home.  In  some  cases  the  disabilily  may  last  for  months  or 
years  and,  in  such  cases,  idleness  is  neither  good  for  the 
patient  nor  the  community.  In  many  cases  there  is  left  behind 
a  permanent  disabilily  which  forever  prevents  return  to  the 
former  vocation. 

The  workman  who  has  had  pneumonia,  unless  he  is  warned 
against  it,  is  apt  to  return  to  some  form  of  laborious  occupa- 
tion whidi,  following  pneumonia,  may  result  in  permanent 


(f" 


60        THE  COMMUNITY  HEALTH  PROBLEM 

injury  to  the  heart.  It  is  not  enough  to  advise  snch  a  man 
against  hard  work.  He  mnst  he  guided  toward  other  work 
for  which  he  is  better  adapted.  The  cripple,  who  has  lost  an 
arm,  easily  becomes  a  permanent  object  of  charity  unless  he 
is  taught  another  form  of  occupation  which  he  is  able  to 
carry  on  in  spite  of  his  disability.  The  man  who  has  been 
a  skilled  workman  and  lost  his  arm  is  apt  to  feel  that  he 
has  lost  his  chance  and  will  never  again  be  able  to  Bup> 
port  his  family.  The  change  in  his  mental  attitude  toward 
the  world  is  remarkable  when  he  finds  that  he  may  be  trained 
for  another  position,  which  will  not  alone  make  him  self 
supporting,  but  will  enable  him  to  earn  as  much  or  more  than 
before  his  injury.  The  Institute  for  Crippled  and  Disabled 
Men  in  New  York  City  makes  a  specialty  of  rehabilitation 
of  disabled  men. 

The  Ford  Motor  Company  boasts  that  a  man  is  never  dis- 
charged from  their  employ  because  of  physical  disability.  If 
he  is  unfit  for  his  former  occupation  he  is  trained  for  another. 
The  entire  plant  was  studied  with  this  in  view  and  it  was 
found  that,  in  a  comparatively  short  time,  the  man  with  a 
handicap  could  be  trained  for  some  form  of  work  for  which 
his  physical  condition  fitted  him.  In  1918  it  is  said  that  in 
the  Ford  factory  there  were  over  9,000  men  at  work  all  of 
whom  had  some  form  of  physical  disability.  On  the  pay  roll 
were  men  without  one  or  both  feet,  men  blind  of  both  eyes, 
men  with  one  or  both  hands  missing,  and  men  with  arms 
or  legs  hopelessly  crippled.  Not  a  few  cripples  but  literally 
thousands  of  them. 

It  is  stated  that,  in  the  Ford  factory,  this  is  not  done  as 
a  work  of  charity  but  as  a  business  proposition  and  that  it 
pays.  Even  patients  with  tuberculosis  when  unsuitable  for 
sanitarium  treatment  are  kept  at  work  in  the  factory 
under  medical  supervision.  These  patients  work  in  a  specially 
constructed  builcQng,  and  are  able  to  support  their  families 
while  they  are  taking  the  cure. 

There  is  probably  no  other  large  corporation  which  has  fol- 
lowed this  plan  as  extensively  as  the  Ford  Company  but  the 


CAMPAIGN  FOR  BETTER  HEALTH     61 

Federal  Board  for  Vocational  Training  which  has  charge  of 
the  rehabilitation  of  disabled  soldiers  is  extending  the  work 
along  somewhat  similar  lines.  The  work  of  vocational  train- 
ing for  industrial  cripples,  of  whom  there  are  an  enormous 
number,  has  received  a  tremendous  impetus  through  the 
efforts  of  the  Federal  Board.  Congress  has  appropriated  a 
sum  of  money  for  the  purpose  of  encouraging  state  activities 
in  this  line.  This  money  is  available  to  states,  in  order  to 
encourage  the  institution  of  vocational  training,  on  the  condi- 
tion that  the  state  appropriate  an  equal  amount  for  the  same 
purpose. 

CABB  OF  THE  TOTALLY  DISABLED 

There  will  remain  even  under  the  best  conditions  of  medical 
care  a  certain  number  of  the  inhabitants  of  every  community 
who  are  totally  disabled  as  far  as  any  gainful  occupation  is 
concerned  and  hopelessly  invalided  according  to  the  present 
state  of  medical  knowledge.  I  say  "according  to  the  present 
state  of  medical  knowledge"  advisedly  because  there  are  hun- 
dreds, previously  considered  incurable,  now  easily  cured  by 
well  recognized  methods  of  medical  and  surgical  treatment. 

The  totally  disabled  includes  the  insane,  certain  classes  of 
epileptics,  persons  in  the  advanced  stages  of  tuberculosis  aJid 
inoperable  cancer,  and  a  few  others.  The  community  must 
recognize  that  these  persons  must  be  considered  a  charge  on 
the  community  as  a  whole  and  not  merely  on  their  nearest 
relatives  or  their  acquaintances. 

How  shall  we  care  for  this  group  of  so-called  "incurables"  ? 
A  few  may  be  left  in  their  home  surroundings,  especially 
when  this  course  assures  reasonably  good  care.  It  is  reasonable 
to  presume  that  when  necessary  the  state  might  pay  for  the 
maintenance  of  such  persons  in  their  homes  rather  than 
undertake  the  expense  of  institutional  care.  However,  the 
larger  part  of  the  totally  disabled,  espefjially  the  insane,  should 
be  treated  in  institutions.  The  concentration  of  various  types 
of  chronic  mental  and  physical  disordears  in  a  large  institution 


>"^ 


62        THE  COMMUNITY  HEALTH  PROBLEM 

pennits  of  their  treatment  at  comparatively  low  cost  and  gives 
promise  of  the  discovery  of  some  form  of  cure  for  at  least  a 
part  of  the  diseases  tmder  treatment.  It  has  been  only  a  few 
years  since  cretinism  was  considered  incurable  and  patients 
with  this  disorder  spent  their  lives  in  asylums.  Now  the  dis- 
ease is  recognized  as  a  disorder  of  the  thyroid  gland  and  easily 
cured  by  appropriate  thyroid  treatment.  As  much  may  pos- 
sibly be  accomplished  in  the  future  for  other  diseases  now 
considered  incurable. 

There  is  another  very  potent  reason  for  institutional  care 
of  the  so-called  incurables.  Most  of  them  do  much  bettor 
when  removed  from  the  excitement  of  modem  life  and  in 
institutions  arrangements  can  be  made  so  that  many  of  the 
unfortunates  may  be  kept  busy  with  some  form  of  light  occu- 
pation which  keeps  the  mind  busy  and  body  healthy. 

LINES  OF  ENDEATOB 

In  attacking  the  problem  of  community  health  there  are 
certain  lines  of  endeavor  along  which  efforts  for  better  health 
may  be  carried  out.  Most  of  these  have  been  already  studied 
witii  great  care  and  as  a  result  of  the  experience  of  others 
there  is  considerable  cumulative  information  available.  Along 
fiome  of  the  lines  which  will  be  mentioned  there  are  already 
national  organizations  with  many  brandies.  Others  have  been 
developed  by  the  state  or  local  departments  of  health  or  local 
welfare  organizations. 

In  the  organization  of  any  form  of  community  health  move- 
ment it  is  well  to  divide  the  work  so  that  various  workers  have 
their  duties  definitely  outlined.  In  large  communities  a  sepa- 
rate committee  can  be  appointed,  if  thought  desirable,  for 
each  separate  health  problem. 

The  prevention  of  accidents,  both  industrial  and  non- 
industrial  has  recently  been  emphasized  by  the  "Safety  First** 
movement.  Much  may  be  accomplished  by  a  study  of  the  acci- 
dents occurring  during  a  given  period,  and  by  legal  measures 
adopted  to  diminish  such  accidents.   Closely  related  to  acci- 


CAMPAIGN,  FOE  BETTER  HEALTH  63 

dent  prevention  is  the  prevention  of  industrial  disease.  If  a 
suryej  of  industiy  clearly  shows  the  prevalence  of  diseases 
caused  by  working  conditions  it  should  be  a  comparatively 
simple  measure  to  institute  reforms  leading  to  their  cor- 
lection. 

The  prevention  of  infection  through  the  transmission  of 
food  and  water-borne  diseases  is  ordinarily  considered  among 
the  duties  of  the  local  board  of  health.  If  such  diseases  are 
occurring  to  a  greater  degree  than  in  other  similar  communi- 
ties popular  appreciation  of  the  fact  will  lead  to  action  by 
the  local  authorities. 

Pre-natal  care,  maternity  care  and  infant  welfare  work  may 
well  be  associated.  There  is  a  strikingly  large  number  of  still- 
births, and  deaths  during  the  £rst  mon^  of  life,  in  the  United 
States.  Too  many  by  far,  in  view  of  the  fact  that  it  has  been 
shown  that  by  proper  care  this  number  can  be  greatly  de- 
creased. The  records  of  the  Henry  Street  Settlement  show- 
ing the  effects  of  district  nursing  upon  infant  mortality  rates 
have  been  most  instructive.  Is  your  commimiiy  doing  all 
that  it  should  do  for  expectant  mothers  and  for  newly  ar^Ted 
infants? 

During  the  first  few  years  of  life,  before  the  school  age,  is 
8  period  which  is  often  neglected.  Children  as  a  rule  appear 
healthy  and  parents  are  apt  to  dismiss  signs  of  illness  in  the 
hope  that  "the  child  will  outgrow  it.** 

Children's  welfare  during  ihe  school  period  is  of  extreme 
importance.  This  offers  an  especially  favorable  occasion  to 
oversee  the  child's  health  because  children  are  easily  reached 
in  the  public  schools  and  many  can  be  kept  under  super- 
vision for  a  comparatively  small  expense.  Mal-nutrition  is 
possibly  the  most  common  serious  aJBfection  which  occurs  at 
this  age.  Enlarged  tonsils  and  adenoids  and  defective  teeth 
should  be  cared  for  at  this  time  in  order  to  obtain  the  best 
results.  During  the  same  period  the  training  of  crippled 
children  for  gainful  occupations  should  begin. 

About  the  time  the  child  leaves  grammar  school  the  war 
against  diseases  of  venereal  origin  should  be  begun.  Instruc- 


64        THE  COMMUNITY  HEALTH  PEOBLEM 

tion  of  the  child  as  to  sex  dangers  and  other  measures  to  pre- 
vent the  spread  of  these  diseases  should  not  be  neglected.  It 
is  not  the  intention  here  to  offer  a  solution  of  the  problem  of 
venereal  disease  but  rather  to  impress  upon  the  reader  that 
in  any  community  the  problem  must  be  met  and  that  a 
definite  policy,  especially  adapted  to  the  needs  of  that  par- 
ticular community,  should  be  rigorously  carried  out.  The 
National  Social  Hygiene  Society  is  prepared  to  give  advice 
and  to  indicate  measures  which  may  be  expected  to  produce 
results.  The  almost  complete  elimination  of  this  disease  in 
the  American  Expeditionary  Forces  would  indicate  that  a  solu- 
tion of  the  venereal  problem  is  possible.  Can  we  make  prac- 
tical use  of  the  same  solution  in  a  given  civilian  community? 
Tuberculosis  we  have  always  with  us.  It  is  estimated  that 
about  one  death  in  ten  in  the  IJnited  States  is  due  to  pul- 
monary tuberculosis.  Worse  than  this  is  the  fact  that  most 
of  the  deaths  occur  in  young  adults.  WhUe  a  cure  is  in  many 
cases  possible  it  is  a  tedious  procedure  and,  for  economic 
reasons,  diflBcult  to  accomplish.  It  is  not  enough  to  tell  the 
Bujfferer  that  he  must  move  to  a  'Tiigh,  dry  climate,*'  or  the 
arrested  case  that  he  must  secure  'light  out-door  work"  and 
then  to  dismiss  the  subject.  Every  case  of  tuberculosis  is  a 
potential  source  of  infection  and  the  problem  is  a  community 
problem  and  must  be  met  as  such.  The  National  Tuberculosis 
Association  is  ready  to  furnish  almost  unlimited  information 
on  the  care  of  these  cases  and  can  render  valuable  assistance 
in  fighting  the  disease.  The  Metropolitan  Life  Insurance 
Company  has  been  making  a  three-year  experiment  on  com- 
munity control  of  pulmonary  tuberculosis  at  Framingham, 
Mass.,  where  results  would  indicate  that  there  are  several 
unrecognized  cases  of  the  disease  for  every  one  which  ordi- 
narily comes  under  treatment.  The  work  of  the  Ford  Com- 
pany in  taking  an  active  interest  in  such  patients  and  put- 
ting them  in  emplojrment  commensurate  with  their  physical 
ability  has  already  been  mentioned.  The  experiment  will  bear 
watching. 


CAMPAIGN,  FOB  BETTEB  HEALTH      65 

HOSPITAL  AKD  H03IE  CABS 

The  hospital  care  of  acute  illness  has  been  fairly  well 
worked  out,  especially  in  the  larger  cities.  In  rural  districts 
and  smaller  cities  hospital  care  for  the  poor  is  often  unob- 
tainable. 

The  home  care  of  the  seriously  ill  is  much  less  satisfactory 
if  we  consider  the  community  as  a  whole.  Visiting  nursing 
can  accomplish  a  great  deal  to  make  for  better  treatment. 
It  is  said  that  even  under  the  best  conditions  nine  persons 
are  cared  for  in  the  home  to  each  one  taken  to  a  hospitaL 
Look  through  the  homes  of  the  poor  and  see  if  they  receive 
even  reasonably  good  care.  Question  the  self-supporting  wage 
earner  and  see  if  he  is  taking  advantage  of  tiie  benefits  of 
modem  scientific  medicine.  See  how  much  money  he  spends 
for  medical  care  and  medicines  and  stop  and  figure  if  he 
actually  gets  full  value  for  his  money.  I  have  no  figures  avail- 
able for  the  amount  spent  annually  for  patent  medicines, 
which  seldom  do  good  and  often  cause  serious  injury,  but 
I  am  sure  the  total  must  be  enormous. 

It  has  seemed  to  me  that  routine  medical  and  dental  care, 
that  is,  the  care  required  by  the  individual  for  most  of  the 
minor  ills  which  flesh  is  heir  to,  has  been  better  met  in  cer- 
tain up-to-date  industrial  communities  than  under  the  charity 
dispensary  system  of  our  large  cities.  The  Endicott-Johnson 
Company,  of  Binghamton,  N.  Y.,  the  Standard  Oil  Company 
of  New  Jersey,  Cheney  Brothers,  of  Manchester,  Conn.,  and 
many  others  have  undertaken  almost  complete  care  of  their 
employees  apparently  with  excellent  results  and  at  a  minimum 
cost  for  the  service  rendered.  Health  Insurance  undertakes 
the  same  daily  care  of  the  sick  and  has  worked  fairly  well 
in  Qermany  and  England.  It  has  not  been  tried  as  yet  in  the 
United  States  although  several  commissions  in  various  states 
have  been  appointed  to  study  the  question  and  health  insur- 
ance acts  in  some  form  have  been  introduced  in  the  legislature^ 
of  sereral  states. 


/" 


66        THE  COMMUNITY  HEALTH  PBOBLEM 

Another  question  which  mnst  be  met  and  which  is  at  pres- 
ent receiving  comparatively  little  attention  is  the  placing  of 
individuals  seriously  handicapped  by  disease  in  gainful  occu- 
pations. War  cripples  are  being  trained,  industrial  cripples 
are  soon  to  be  trained,  but  persons  handicapped  by  chronic 
diseases  are  seldom  given  the  attention,  with  reference  to 
industrial  classification,  which  the  seriousness  of  their  con- 
dition surely  deserves. 

In  mapping  out  the  lines  of  endeavor  as  outlined  above,  no 
attempt  has  been  made  to  cover  the  entire  field.  An  indication 
of  certain  well-marked  paths,  which  have  been  more  or  less 
successfully  followed  in  the  past  should  be  sufficient  as  a 
working  basis  for  a  start  in  any  form  of  health  movement. 
The  broadening  out  of  the  scope  of  the  work  will  become  self 
evident  once  the  movement  has  been  started.  When  funds  and 
personnel  are  limited  it  is  better  to  choose  one  aspect  of  the 
health  problem  and  seek  for  improvement  by  intensive  effort 
in  a  limited  field  rather  than  to  spread  the  effort  over  too 
much  territory  and  accomplish  few  if  any  tangible  results. 


CHAPTEB  VII 

WORKMEN'S  COMPENSATION  INSURANCE 

During  recent  years  there  has  been  a  rapid  development 
throughout  the  United  States,  of  what  in  this  country  is  a 
new  principle,  the  state  control  of  compensation  for  industrial 
injuries.  Since  AprU,  1911,  when  the  first  general  state  com- 
pensation law  went  into  effect,  the  movement  has  steadily 
spread  from  state  to  state  so  that,  today,  there  are  only  six 
states  which  have  no  statutory  provision  for  workmen's  com- 
pensation. In  addition,  the  federal  government  has  enacted 
a  comprehensive  compensation  law  for  the  protection  of  its 
civilian  employees. 

Briefly,  workmen's  compensation  legislation  is  a  legal  meas- 
ure to  compel  industry  to  repay,  in  terms  of  cash  benefits, 
physical  losses  sustained  by  workmen  in  pursuit  of  their  voca- 
tions. In  other  words,  it  is  the  recognition  by  the  State  of  the 
responsibility  of  industry  for  the  wear  and  tear  of  the  human 
machine. 

For  many  years  it  has  been  the  custom  in  every  well- 
managed  industrial  organization  to  charge  off  a  certain  per 
centage  of  income  for  repairs  and  depreciation  of  buildings 
and  equipment,  but,  imtil  the  advent  of  compensation,  em- 
ployers were  not  compelled  to  suffer  any  loss  for  broken  and 
injured  human  machinery.  The  crippled  workman,  who  be- 
cause of  an  injury  was  unable  to  continue  his  work,  could  be 
tossed  into  the  discard  if  the  employer  so  desired,  even  if  the 
injury  had  arisen  as  a  direct  consequence  of  a  hazardous  occu- 
pation. 

LIABILITT  LAWS 

It  is  not  strictly  true  that  there  was  absolutely  no  redress 
for  industrial  accidents  before  the  enactment  of  compensation 

67 


ft^ 


68        THE  COMMUNITY  HEALTH  PBOBLEM 

laws.  There  was,  it  is  trae,  the  principle  of  liability  for  aoci* 
dent  under  which  the  workman  might  bring  legal  action  to 
recover  damages.  However,  in  most  states  it  was  required 
that  in  order  to  collect  damages  the  employee  must  show  that 
there  had  been  negligence  on  the  part  of  the  employer. 

This  was,  as  a  rule,  difficult  to  prove  and  often  required 
years  of  litigation  before  the  workman  received  a  verdict. 
Meantime  during  the  course  of  the  trial  he  had  been  put  to 
considerable  expense  of  both  time  and  money.  Few  employees 
had  sufficient  funds  to  carry  through  such  prolonged  litiga- 
tion and,  as  a  consequence,  they  were  usually  forced  by  cir- 
cumstances to  employ  a  lawyer  who  would  finance  the  case 
from  his  own  pocket  in  the  hope  of  a  favorable  verdict. 
Naturally  the  legal  fees  were  very  high.  Under  such  condi- 
tions there  developed  a  group  of  so-called  "ambulance  chasers," 
unscrupulous  lawyers  who  were  anxious  to  exploit  the  injured 
workman  for  their  own  benefit.  Fees  of  fifty  per  cent,  of  the 
total  were  common;  and  fees  and  expenses  equivalent  to 
eighty  per  cent.,  or  more,  were  not  rare.  The  result  of  this 
was  ^at  the  injured  workman  had  slight  incentive  to  appeal 
to  law  and  it  often  happened  that  he  preferred  to  shoulder 
his  loss  without  attempting  to  recover  for  either  the  loss  of  his 
time  or  for  his  physical  disability. 

The  sum  total  was  that  the  companies  were  obliged  to  spend 
large  sums  for  liability  insurance,  the  courts  were  crowded 
with  accident  cases,  the  surgical  care  of  the  injured  workman 
was  thrown  on  medical  charity  and  the  patient  became  a 
charge  on  the  community.  No  one  benefited  except  certain 
members  of  the  legal  profession.  In  all  fairness  to  the  legal 
profession  it  should  be  said  that,  as  a  whole,  they^strongly 
objected  to  such  a  condition  and  legislation  for  its  correction 
was  urged. 

Some  of  the  larger  employers,  to  their  credit,  accepted  the 
responsibility  and  voluntarily  took  every  measure  to  prevent 
accidents  and  compensate  injured  workers.  However,  in  the 
main,  conditions  may  be  said  to  have  been  almost  uniformly 
bad. 


y^ 


WORKMEN'S  COMPENSATION  INSUEANCE    69 

WaAX  COHPEKSATION  AOCOUPUSHZD 

At  one  stroke  the  compensation  acts  did  much  to  abolish 
these  abuses.  The  difficulty  of  determining  responsibility  for 
accidents  was  recognized  and  consequently  every  accident  was 
made  compensable  even  in  those  cases  in  which  it  could  be 
shown  that  there  had  been  contributory  negligence  on  the  part 
of  the  employee.  The  law  recognized  the  "ambulance  chaser*' 
nuisance  and  made  the  compensation  act  the  only  law  appli- 
cable  to  industrial  accidents,  even,  in  some  states,  forbidding 
the  payment  of  a  fee  for  legal  services  in  connection  with 
compensation  cases,  unless  it  was  clearly  evident  that  such 
legal  advice  was  required.  The  burden  of  disability  was 
removed  from  the  community  and  placed  upon  industry 
where  it  belonged.  The  disabled  worker,  instead  of  being  an 
object  of  charity,  became  a  pensioner  of  the  industry  which 
had  crippled  him. 

As  a  rule  compensation  includes  medical  and  surgical  care, 
medical  supplies  and  a  cash  benefit  during  the  period  of  dis- 
ability. In  case  of  death  there  is  a  funeral  benefit  and  a 
pension  for  the  widow  and  dependent  children. 

MEDICAL  ATTENTIOir 

All  the  compensation  laws  except  those  of  Alaska,  Ari- 
zona and  New  Hampshire  provide  for  medical  attention. 
Most  states  require  the  employer  to  furnish  in  addition  med- 
ical supplies  and  hospital  services  when  needed.  There  is, 
however,  considerable  variation  in  the  service  supplied,  some 
states  limiting  the  amount  to  be  spent  and  others  limiting 
the  period  during  which  treatment  is  to  be  paid  for.  Aside 
from  the  humanitarian  standpoint,  the  limitation  of  treat- 
ment to  two  or  three  weeks,  as  is  the  legal  requirement  in 
some  states,  is  economically  bad  because  it  prevents  ade- 
quate treatment  in  the  cases  which  need  it  most.  There  is 
the  same  objection  to  the  limitation  of  medical  fees  to  a 
Gomparatiyely  small  amount,  such  as  fifty  or  a  hundred  dol- 


^' 


70        THE  COMMITNITY  HEALTH  PROBLEM 

laTs,  for  this  tends  to  prevent  sufficient  and  adequate  treat- 
ment for  the  severe  injuries.  Unlimited  treatment  is  apt  to 
lead  to  abuse  of  the  privilege,  but  medical  care  for  at 
least  two  months  should  be  given  with  additional  treatment 
optional  upon  the  decision  of  the  accident  board.  The 
medical  fees  should  be  sufficient  to  insure  adequate  and  skill- 
ful care.  Excessive  fees  may  be  guarded  against  by  careful 
regulations. 

CASH.  BENEFITS 

By  far  the  best  method  of  compensation  for  wage  loss  is 
a  cash  benefit  up  to  a  certain  percentage  of  the  weekly  wage. 
For  practical  purposes  this  benefit  has  been  fixed  in  most 
states  at  66-2/3  per  cent,  during  the  period  of  total  disabil- 
ity, continuing  us  long  as  the  total  disability  exists.  The 
cash  compensation  should  always  be  considerably  less  than 
the  weekly  wage  in  order  to  discourage  malingering  and,  in 
a  sense,  in  order  to  compensate  for  the  fact  that  contribu- 
tory negligence  on  the  part  of  the  employee  does  not  deny 
him  the  right  to  compensation. 

For  partial  disability  the  workman  should,  theoretically, 
receive  a  part  of  the  reward  proportioned  to  the  extent  of 
his  disability  as  measured  by  the  wage  loss,  but  from  a  prac- 
tical standpoint  this  loss  is  very  difficult  to  estimate.  In 
many  cases  compensation  for  partial  disability — ^the  loss  of  a 
finger  or  hand  for  example — is  made  by  the  payment  of  a 
lump  sum. 

Death  benefits  payable  to  the  widow  or  other  dependents 
are  usually  figured  at  35  per  cent,  of  the  decedent's  wages  at 
the  time  of  death.  To  the  widow  the  payments  are  kept  up 
for  life  or  until  remarriage.  The  widow  receives  two  years 
compensation  in  a  lump  sum  on  remarriage.  Compensa- 
tion is  also  paid  to  dependent  children  and  certain  other  de- 
pendents up  to  a  weekly  total  of  66-2/3  per  cent,  of  the  wage 
at  the  time  of  death. 


y"N 


WOEKMEN'S  COMPENSATION  INSUEANCE    7i 

EHPLOTHENTS  INCLUDED 

When  the  compensation  laws  were  first  introdnced  efforts 
were  concentrated  upon  what  are  known  as  the  "hazardons" 
employments  and  in  most  states  the  acts  as  finally  passed 
included  only  this  class  of  employees.  In  many  states,  how- 
ever, the  law  has  been  broadened  to  include  all  employees  ex- 
cept farm  and  domestic  labor.  In  some  states  the  principle 
is  applied  according  to  the  number  of  employees,  those 
employers  of  less  than  a  certain  number,  usually  from  two  to 
ten,  being  exempted  from  the  provision  of  the  act 

In  some  states  casual  labor,  that  is  labor  employed  only  for 
a  few  hours  or  a  day  or  so  at  a  time,  has  not  been  included 
in  the  act.  This  is  because  from  an  administrative  stand- 
point it  would  be  impracticable  for  employers  to  insure  such 
cases,  but  when  a  firm  habitually  employs  casual  labor  they 
should  carry  insurance  to  cover  the  group  employed.  If  the 
principle  of  the  act  is  a  good  one,  and  there  be  no  doubt  on 
this  point,  there  can  be  no  objection  to  the  inclusion  of  all 
employees,  even  domestic  and  farm  labor.  The  difficulties 
arise  more  from  the  complexities  of  the  execution  of  such 
a  law  when  applied  to  small  employers  than  from  any  failure 
of  the  principle  of  compensation  in  all  cases. 

ADlflNISTBATION 

Most  compensation  laws  are  administered  by  a  commission 
appointed  by  the  Grovemor.  In  some  cases  the  commission 
has  power  to  increase  or  decrease  the  amount  of  compensa- 
tion and  the  period  and  cost  of  medical  care.  In  others, 
their  powers  are  limited  to  a  considerable  extent  either  by 
state  laws  or  regulations. 

It  is  important  that  such  a  board  or  commission  shall  be 
composed  of  men  who  devote  their  entire  time  to  the  work 
and  that  the  personnel  include  men  of  clear  vision  and  keen 
nnderstanding  of  modem  social  problems.  As  a  rule,  the 
findings  of  the  accident  boards  are  final  and  cannot  be 
reviewed  by  the  courts. 


/I^S 


.J 


n       THE  COMMUNITY  HEALTH  PKOBLEM 

INSUEAKCX  OAfiBISBS 

Infforance  may  be  carried  by  a  state  fund,  by  a  mutoal 
insuranoe  fund,  by  commercial  insurance  carriers  or  by 
Tarious  combinations.  In  some  states*  corporations  are  allowed 
to  maintain  their  own  insurance  fund  subject  to  the  approval 
of  the  proper  administrative  authorities. 

In  most  states,  insurance  in  a  commercial  company  is 
permitted  but  this  should  be,  and  generally  is,  subject  to 
restrictions  and  rigid  supervision,  in  order  to  prevent  insolv- 
ency. 

State  insurance  funds  have  been  started  in  New  York, 
Ohio,  California  and  many  other  states.  In  general  they 
have  worked  fairly  well  and  are  rapidly  extending.  Mutual 
insurance  associations  are  permitted  in  many  states.  They 
have  perhaps  worked  better  than  state  funds  not  being  con- 
fined 80  closely  by  laws  and  regulations.  They  should,  of 
course,  be  carefully  supervised  by  the  state  insurance  authori- 
ties. 

Iin>nSTBIAL  DISEASES 

As  a  rule  industrial  diseases  have  not  been  considered  as 
injuries  within  the  meaning  of  the  various  compensation  acts. 
Thus,  if  a  man  contracts  lead  poisoning  while  at  work  as  a 
painter  he  is  awarded  compensation  in  only  four  states ;  Cali- 
fornia, Connecticut,  Massachusetts  and  Wisconsin.* 

There  can  be  no  doubt  that  all  industrial  diseases  should  be 
compensated  for,  just  as  are  injuries,  but  the  difficulty  has 
been  that,  from  a  practical  standpoint,  it  is  very  hard  to 
say  just  when  a  man  contracts  a  given  disease.  If  a  man 
finally  contracts  a  chronic  industrial  disease,  such  as  lead 
poisoning,  after  several  years  of  work  at  his  trade  as  a  painter, 
it  is  probable  that  he  has  been  absorbing  small  quantities  of 
lead  for  many  years  and  that  the  disease  is  the  result  of  this 
process  long  continued  which  has  finally  resulted  in  disability. 

*Slne«  the  aboT*  was  written  tli«  New  York  State  CompeaaatioB  Ati 
has  been  amended  to  ladade  diseases  of  Industrial  origin. 


WOBKMEN'S  COMPENSATION  INSUBANCE    73 

It  seems  hardly  fair  that  his  last  employer  should  suffer  th« 
entire  loss. 

Many  diseases  may  arise  either  from  industry  or  from 
other  unrelated  causes.  In  such  cases  it  is  extremely  difficult 
to  make  the  distinction.  From  a  theoretical  standpoint  there 
is  no  doubt  that  industry  should  bear  the  costs  of  industrial 
diseases.  From  a  practical  standpoint  it  has  been  difficult  to 
formulate  satisfactory  regulations  to  accomplish  this  result. 

COMPENSATION  HAS  BEEN  A  SUCOESS 

There  can  be  no  doubt  that  the  compensation  laws  have 
been  successful,  which  is  not  to  say  that  there  has  not  been 
a  great  deal  of  dissatisfaction  with  the  methods  adopted  in 
the  execution  of  the  various  compensation  acts. 

In  some  states,  the  provision  for  medical  care  is  inadequate 
with  the  result  that  the  medical  profession  feels  imposed  upon 
and  physicians  are  consequently  not  inclined  to  give  their 
best  efforts  to  make  the  law  a  success;  in  certain  states  in- 
surance companies  have  apparently  taken  advantage  of  tech- 
nicalities of  the  law  thereby  diminishing  the  compensation 
and  medical  benefits  in  direct  opposition  to  the  spirit  of  the 
act;  and,  worst  of  all,  in  some  states  there  have  been  evidences 
of  petiy  graft  which  has  acted  to  deprive  injured  workers  of 
their  just  rewards.  Minor  office  holders  have  induced  injured 
and  ignorant  workmen  to  promise  them  a  percentage  of  the 
award  on  the  false  presumption  that  their  influence  would  be 
required  to  secure  a  settlement,  and  other  similar  petty  dis- 
honesties have  been  occasionally  practised. 

In  almost  every  state  there  were  misunderstandings  and 
delays  due  to  untrained  personnel  which,  at  first,  caused  a 
great  deal  of  dissatisfaction  among  workmen,  employers  and 
physicians.  However,  as  experience  increases,  delays  and  mis- 
understandings are  lessened  and  the  law  works  more 
smoothly. 

On  the  whole  the  principle  of  compensation  has  be^i  a 
success.     The  injured  workman,  today,  receives,  as  a  rule. 


74        THE  COMMUNITY  HEALTH  PEOBLEM 

better  medical  care  than  he  received  previoiuly,  together  with, 
a  cash  benefit  which  has  no  taint  of  charity.  The  legal  con- 
flicts, with  the  consequent  bad  feeling  on  both  sides,  previ- 
ously exceedingly  common,  are  now  extremely  rare.  This 
in  turn  causes  him  to  be  more  loyal  to  his  employer  and  a 
better  citizen  in  the  community  at  large. 

New  laws  and  modifications  of  the  present  laws  should  be 
carefully  drafted  so  as  to  prevent  injustice  to  any  of  the  parties 
concerned.  They  should  deal  liberally  with  the  employee, 
fairly  with  the  employer,  and  justly  with  the  state  and  the 
community. 

THE   USB   OF   SATETY   DEVICES   TSOSEASED 

While  compensation  insurance  is  of  too  recent  origin  in 
this  country  to  demonstrate  fully,  in  all  details,  its  value  for 
the  prevention  of  accidents,  the  rapid  increase  in  the  use  of 
safety  devices  on  all  forms  of  dangerous  machinery  clearly 
indicates  the  tendency  in  this  direction.  Both  the  employer 
and  the  insurance  carrier  have  a  direct  financial  interest  in 
the  prevention  of  injury  and  this  fact,  together  with  the  care- 
ful records  which  are  now  kept,  has  led  to  the  adoption  of 
many  new  and  original  forms  of  machinery  safeguards.  In 
certain  cases  the  employer  may  obtain  a  lower  insurance  rate 
if  he  introduces  approved  forms  of  guards  against  acci- 
dents and,  in  many  states,  industrial  conmiissions  have  ruled 
that  extra  hazardous  machinery  must  be  equipped  with  safe- 
guards of  a  design  approved  by  the  commission. 


CHAPTEB  Vni 

COMPULSORY  HEALTH  INSURANCE 

With  the  introduction  of  Workmen's  Compensation  Insur- 
ance in  this  country,  a  new  conception  of  community  responsi- 
bility for  health  spread  rapidly  over  the  United  States.  What 
had  been  apparent  to  students  of  sociology  and  human  welfare 
for  many  years  suddenly  became  apparent  to  all.  It  was 
recognized  that  losses  due  to  injuries  arising  as  a  result  of  a 
particular  occupation  should  be  borne  by  industry  as  a  part 
of  the  costs  of  operation,  and  not  by  the  individual,  and  it 
was  further  recognized  that  it  was  the  duty  of  the  various 
states  to  protect  the  worker  against  such  losses  by  means  of 
well  considered  constructive  legislation. 

Beasoning  along  similar  lines  the  conclusion  is  soon  reached 
that  as  all  sickness  arises  from  causes  found  either  in  the 
individual,  or  his  work,  or  in  the  communiiy  at  large,  the 
costs  of  sickness,  as  a  logical  consequence,  should  be  met  not 
by  the  individual  alone  but  by  a  common  fund  made  up 
from  equitable  contributions  of  all  concerned. 

Knowing  that  the  sum  total  of  disability  is  not  large  and 
that  the  expense  of  treatment  can  be  easily  met  if  the  loss 
is  distributed  among  all  workers,  whereas  the  cost  of  sick- 
ness is  frequently  overwhelming  to  the  individual  wage 
earner,  the  modem  method  of  insurance  against  loss  at  once 
suggests  itself.  Consequently  compulsory  health  insurance, 
or  co-operative  sickness  insurance  as  it  is  sometimes  called, 
has  been  advanced  as  the  solution  of  the  problem  of  untreated 
disease,  and  as  a  remedy  for  the  relief  of  economic  loss  due 
to  physical  disability. 

Health  insurance  while  new  in  the  United  States  has  been 
successfully  carried  out  for  many  years  in  various  European 

75 


76        THE  COMMUNITY  HEALTH  PBOBLEM 

comitries.  It  was  introduced  over  thiriy  yeaiB  ago  in  Qer- 
many  and  spread  rapidly.  In  England,  health  insurance  was 
introduced  in  1911  but,  because  of  the  beginning  of  the  "World 
War  in  1914,  confusion  has  arisen  in  its  administration  so 
that  it  is  now  undergoing  considerable  re-organization  in 
order  that  it  may  function  smoothly  on  a  peace  basis. 

In  1916,  the  American  Association  of  Labor  Legislation, 
after  careful  study  of  the  health  of  the  wage  earner  and 
of  methods  for  the  correction  of  poverty  due  to  injury  and 
disease,  formulated  a  tentative  draft  of  an  act  which  would 
make  the  benefits  of  health  insurance  available  to  all  wage 
earners.  Legislative  action  based  upon  this  tentative  draft 
has  been  instituted  in  several  states  but  up  to  the  present 
no  state  has  actually  passed  any  form  of  law  for  the  intro- 
duction of  health  insurance.  Several  state  commissions  have 
been  appointed  to  ihvestigate  the  need  of  such  a  law,  and  in 
general,  the  reports  of  these  commissions  have  confirmed  the 
premises  assumed  by  the  originators  of  the  tentative  draft, 
namely  that  there  is  an  immense  amount  of  xmtreated  illness 
and  that  a  considerable  number  of  cases  of  poverty  arise 
primarily  as  a  result  of  economic  loss  due  to  physical  dis- 
ability. In  spite  of  these  findings  legislatures  have  failed  to 
act,  not  as  a  rule,  because  the  need  was  not  apparent,  but 
because  they  were  uncertain  as  to  the  ability  of  health  insur- 
ance measures  favorably  to  influence  existing  conditions. 

WHAT   HEALTH   IN8UBAKCE   MEANS 

Health  insurance  as  it  has  been  advocated  in  this  country 
includes  three  benefits:  A  cash  benefit  (based  upon  the 
worker's  salary)  during  the  period  of  disability;  a  death  bene- 
fit which  is  usually  a  fixed  sum;  and  medical  and  nursing 
care  for  all  illness  whether  incapacitating  or  not. 

To  these  benefits  have  been  added,  in  some  drafts  of  the 
acty  a  maternity  benefit  for  insured  women  workers  or  for 
the  wives  of  insured  male  workers  and  a  pension  benefit  for 
dependents  of  insured  persons  who  become  totaUy  disabled. 


COMPULSORY  HEALTH  INStTRANCB  77 

In  some  cases  plans  for  inpurance  have  been  extended  to 
include  not  only  the  worker  but  his  family  as  wtlL 

The  cost  of  health  insurance  is  to  be  met  by  premiums  paid 
in  part  by  the  insured,  in  part  by  the  employer  and  in  part 
by  the  State.  The  figures  frequently  quoted  are  40  per  cent 
by  the  wage  earner,  40  per  cent,  by  the  employer,  and  20 
per  cent,  by  the  State,  but  there  is  no  fixed  rule  for  the  divi- 
sion of  the  premium. 

The  insurance  may  be  carried  either  by:  (1)  The  State; 
(2)  Approved  societies  as  in  England;  (3)  Mutual  associa- 
tions as  in  Germany.  As  a  rule  the  American  plan  has  dis- 
regarded the  commercial  insurance  carriers. 

The  cash  benefit  is  usually  limited  to  twenty-six  weeks  in 
any  one  year  and  medical  and  surgical  supplies  are  furnished 
within  certain  prescribed  limits.  The  maternity  benefit  in- 
cludes medical  care  and  a  weekly  cash  benefit  for  eight  weeks. 
Hospital  treatment  and  laboratory  examinations  are  to  be 
furnished  when  necessary. 

In  order  to  prevent  malingering  or  prolongation  of  dis- 
ability among  those  who  find  that  *Ht  pays  to  be  sick"  there 
is  usually  a  waiting  period  of  several  days  before  the  cash 
benefit  begins  and  the  amount  of  the  cash  benefit  is  fixed  so 
as  not  to  exceed  two-thirds  of  the  weekly  salary.  Medical 
treatment  is  given  freely  however  at  all  times  without  regard 
to  other  benefits. 

The  death  benefit  is  usually  a  fixed  amount,  say  $200, 
although  this  can  be  made  to  vary  according  to  the  size  of  the 
family  if  it  is  thought  desirable. 

Administration  is  ordinarily  left  under  the  control  of  the 
organizations  carrying  the  insurance  but  the  expenditures  are 
snpervlBed  by  state  authorities. 

WHY  INSUEANOB? 

It  is  hardly  necessary  to  bring  forth  arguments  for  insur- 
ance as  a  protection  against  economic  losses  due  to  sickness. 
Insurance  against  fire,  insurance  against  death,  and  insurance 


78        THE  COMMUNITY  HEALTH  PEOBLEM 

against  other  losses  are  so  firmly  fixed  in  the  American  mind 
that  no  argument  is  required  to  sustain  the  sonndness  of  the 
principle. 

It  should  be,  theoretically,  easy  to  compute  the  premiums. 
We  know  for  example  that  the  working  man  will  on  the 
average  lose  about  nine  days  every  year  on  account  of  sick- 
ness* and  that  from  20  to  30  per  cent,  of  the  workers  will  be 
flick  every  year.  We  know  that  65  per  cent,  of  those  ill 
more  than  a  week  will  be  back  at  work  within  four  weeks, 
that  about  half  the  balance  will  be  back  at  work  before  the 
eighth  week,  that  only  about  10  per  cent,  will  be  sick  more 
than  three  months  and  that  only  about  three  per  cent,  will 
be  ill  longer  than  six  months.  From  an  insurance  stand- 
point, leaving  out  of  consideration  the  human  equation,  the 
losses  should  be  easily  calculated.  Practically,  this  being  a 
new  form  of  insurance  in  this  country,  the  calculated  pre- 
mium would  probably  require  considerable  modification. 

It  has  been  claimed  that  health  insurance  will  favor  malin- 
gering and  that  the  loss  will  be  greatly  increased  by  pre- 
tended illness.  This  is  of  course  possible  and  will  no  doubt, 
to  a  certain  extent,  increase  expenditures,  but  to  expect  this 
tendency  to  be  so  prevalent  as  to  nullify  the  insurance  princi- 
ple is  to  lose  faith  in  the  bulk  of  the  American  people.  Houses 
have  been  burned  down  to  collect  insurance  and  ships  have 
been  sunk  for  the  same  purpose  but  neither  fire  nor  marine 
insurance  has  been  considered  theoretically  at  fault  because  of 
isolated  instances  of  the  abuse  of  the  insurance  privilege. 

WHY  OOMPULSORY  INSURANCE? 

The  word  compulsory  has  been  used  in  connection  with 
health  insurance  and  has  given  offense  to  many.  The  op- 
ponents of  this  form  of  health  movement  say  that  compulsion 
is  out  of  keeping  with  American  ideals,  that  Americans 
will  not  submit  to  it,  and  that  while  voluntary  insurance  may 
be  all  right  compulsory  insurance  is  objectionable.   Yet  we 


> 


COMPULSOBY  HEALTH  INSURANCE         79 

have  compulsory  education,  compnlBOTy  taxes  and  compnlsion 
in  the  execution  of  our  laws. 

Voluntary  health  insurance,  unlike  life  insurance,  has 
never  been  widely  successful.  Wage  earners  during  early 
life  do  not  take  out  voluntary  sickness  insurance  so  that  most 
commercial  insurance  of  this  type  is  written  for  people  over 
forty  years  of  age,  during  the  period  in  which  sickness  is 
most  common.  Moreover  the  cost  of  any  form  of  commercial 
voluntary  health  insurance  is  very  high,  being  increased 
largely  because  of  commissions  and  overhead  expenses.  As  a 
result,  for  the  premium  paid  the  benefits  derived  are  com- 
paratively small  in  this  form  of  voluntary  insurance.  Under 
the  plans  presented  in  this  country  for  compulsory  insur- 
ance the  premiums  would  be  collected  directly  from  the 
employer  so  that  the  cost  of  collection  would  be  greatly 
decreased ;  all  workers  would  be  included,  thereby  making  the 
premium  comparatively  small;  and  administration  would  be 
in  the  hands  of  mutual  organizations  thus  making  the  per 
capita  overhead  cost  almost  negligible. 

THE  ATTITUDE  OP  THE  PHYSICIAN 

The  vast  majority  of  all  physicians  are  opposed  to  health 
insurance.  While  certain  physicians  of  wide  experience  have 
advocated  its  adoption,  most  oppose  it  in  any  form.  It  is. 
claimed  that  it  will  make  all  physicians  government  employ- 
ees, that  they  will  be  obliged  to  work  for  less  than  a  living 
wage  and  that  it  will  stifle  personal  initiative  and  hinder 
medical  progress. 

Under  health  insurance  the  sick  must  of  necessity  be  cared 
for  by  the  body  of  the  medical  profession  as  it  now  exists. 
Medical  attendance  may  be  secured  in  one  of  three  ways: 
(1)  By  free  dioice  of  physicians;  (2)  By  a  panel  system  such 
as  is  imder  trial  in  England;  (3)  By  salaried  physicians  in 
the  employ  of  the  State. 

The  physicians  have  stood  firmly  for  "free  choice"  and  this 


^1 


80        THE  COMMUNITY  HEALTH  PBOBLEM 

proviBo  was  introduced  into  the  Davenport  Bill  which  was 
passed  by  the  New  York  Senate  in  1919.  There  is  mnch 
to  be  said  in  favor  of  free  choice  and  a  great  deal  against 
it  If  a  patient  is  allowed  to  choose  his  physician  from 
among  all  practising  physicians  who  are  willing  to  treat  him 
he  vill  have  more  confidence  in  his  treatment  than  if  he  is 
forced  to  go  to  a  special  doctor  or  clinic.  On  the  other  hand 
free  choice  will  pnt  a  premium  on  the  advertising  doctor. 
It  will  cause  a  considerable  amount  of  so-called  medical 
shopping.  Patients  will  travel  from  physician  to  physician  in 
order  to  secure  a  diagnosis  which  suits  their  own  conveni- 
ence. It  will  vastly  complicate  the  keeping  of  records  and 
tend  to  increase  expenses. 

In  the  panel  system  all  physicians  who  are  willing  to 
practise  under  the  health  insurance  act  are  placed  on  a  panel 
and  the  workmen  must  choose  a  panel  physician  to  care  for 
him  for  a  definite  period — ^usually  a  year.  The  physician  is 
paid  a  certain  fixed  sum  per  capita.  The  disadvantage  of  this 
system  is  found  in  the  fact  that  the  physician  is  required, 
for  a  limited  fee,  to  give  unlimited  personal  service,  and  serv- 
ice under  such  conditions  is  rarely  found  to  be  satisfactory 
either  to  the  phjrsician  or  the  patient. 

There  is  the  same  objection  to  the  salaried  physician  if 
his  services  are  secured  by  contract.  However  if  the  salaried 
physician  is  made  a  state  employee,  given  an  adequate  salary 
with  a  chance  for  promotion  and  a  career  as  a  public  health 
official  the  objection  is  less  potent  and  under  such  conditions 
many  very  able  physicians  might  be  induced  to  devote  their 
services  to  the  public. 

However,  at  the  present  time,  most  physicians  prefer  to 
be  independent  and  to  work  out  their  futures  according  to 
their  individual  desires  and,  for  this  reason,  they  strongly 
oppose  the  introduction  of  health  insurance  in  any  form.  On 
the  other  hand  there  are  a  few  among  the  medical  profession 
who,  seeing  the  vast  amount  of  untreated  sickness  and  pre- 
ventable disease,  believe  that  health  insurance  offers  a  prac- 
tical remedy  and  urge  its  adoption. 


COMPULSOEY  HEALTH  INSUEANCE         81 

THS  ATTrrUDB  OF  THE  FDBLIO 

Insurance  against  illness  has  been  sponsored  by  welfare 
organizations  and  by  many  individuals  but  in  the  main  the 
public  has  been  unresponsive. 

Certain  labor  organizations  have  been  impressed  by  the 
large  amount  of  idleness  due  to  physical  disabiliiy  and  in 
New  York  the  State  Federation  of  Labor  went  on  record  aa 
in  favor  of  the  introduction  of  health  insurance  legislation. 

The  sick  and  the  needy,  those  who  would  be  benefited,  are 
not  in  a  position  to  make  their  desires  known.  The  healthy 
workman  is  not  inclined  to  worry  about  sickness  in  the  future 
and  the  so-called  middle  classes  are  not  particularly  touched 
by  the  problem  of  untreated  disease  and  its  consequences. 

The  daily  newspapers,  which  do  much  to  influence  public 
opinion,  are,  as  might  be  expected,  somewhat  divided  in 
opinion.  However  it  may  be  stated  without  fear  of  con- 
tradiction that  a  part  at  least  of  the  editorial  opinion  in  the 
larger  cities  has  come  out  imquaUfiedly  in  favor  of  insurance 
of  this  type. 

In  industrial  plants,  where  a  modified  type  of  health  in- 
surance has  been  instituted  voluntarily  by  the  employer,  the 
employees  have  been  almost  universally  in  favor  of  this 
method  of  caring  for  all  cases  of  injury  and  disease. 

In  every  great  movement  whether  for  better  government, 
better  sanitation,  or  better  health  there  is  usually  a  period 
of  education  before  there  may  be  said  to.  be  a  general  public 
demand.  "We  have  just  seen  that  this  was  true  in  regard  to 
suffrage  and  prohibition  and  it  may  be  expected  to  apply 
equally  in  questions  having  to  do  with  public  health.  The 
fact  that  there  is  no  wide  public  demand  for  health  insur- 
ance is  not  a  legitimate  argument  against  it 

PUBLIC  HEALTH  A  FUNCTION  OF  THE  8TATE 

There  can  be  no  question  as  to  the  responsibility  of  the 
community  for  the  health  of  its  citizens.  While  the  extent  of 
<hifl  responsibility  may  be  debatable  the  fact  remains  that. 


^ 


/> 


82        THE  COMMUNITY  HEALTH  PBOBLEM 

to  a  certain  degree,  the  health  of  the  individnal  ia  dependent 
upon  commnnity  conditions  which  can  be  influenced  only  bj 
public  controL  If  this  has  in  the  past  been  met  satisfactorily 
and  in  its  fullest  extent  by  the  activities  of  the  yarious  public 
health  authorities  then  there  is  less  necessity  for  any  form 
of  health  insurance.  If  on  the  other  hand,  the  community 
has  failed  properly  to  safeguard  the  health  of  the  public,  or 
if  it  has  f  died  to  m^ke  available  to  its  citizens  a  reasonably 
adequate  medical  service  for  the  care  of  injury  and  disease, 
then  insurance  against  illness  should  be  seriously  considered 
AS  a  means  of  securing  better  community  health. 

Any  form  of  health  insurance  must  be  closely  related  to 
our  present  public  health  administration,  increasing  its  facili- 
ties and  broadening  its  field  of  action.  In  a  sense  every  physi- 
cian working  under  a  system  of  health  insurance  should  be  a 
health  officer  working  to  diminish  the  sum  total  of  prevent- 
able disease.  He  should  consider  himself  a  public  official 
working  to  increase  public  welfare  in  the  community  and  the 
State. 

We  have  no  definite  data  as  to  the  costs  of  health  insur- 
ance in  the  United  States  so  that,  to  a  certain  extent  at  least, 
it  would  have  to  be  begun  vrith  a  tentative  premium  which 
could  be  easily  changed  as  required  by  experience. 

In  the  consideration  of  insurance  against  sickness  the  fol- 
lowing points  must  be  constantly  borne  in  mind:  (1)  The 
cash  benefit  must  be  smaller  than  the  average  weekly  wage. 
There  must  of  necessity  be  no  premium  placed  upon  idleness ; 
(2)  It  must  include  a  large  group  of  workers  so  that  the 
overhead  expenses  will  be  reduced  to  a  minimum;  (3)  It 
must  contain  provisions  for  adequate  pay  for  both  physicians 
and  nurses,  so  that  the  best  professional  talent  will  be  drawn 
to  the  service;  (4)  The  medical  section  must  contain  provi- 
sions for  hospital  treatment  and  for  the  services  of  special- 
ists; (5)  It  must  be  wisely  administered  and  efficiently  car- 
ried out  so  that  delay  in  payment  of  premium  will  be  avoided 
and  there  will  be  no  question  as  to  the  ability  or  probity  of 
the  officials  or  salaried  employees. 


COMPULSOBY  HEALTH  INSURANCE         83 

If  state  oJ£cia]s,  phyBicians,  nurses  and  othens  concerned 
in  the  execution  of  a  reasonably  satisfactory  form  of  health 
insurance  have  sufficient  vision  and  strength  of  purpose  to  co- 
operate and  work  for  the  best  interrats  of  the  public  welfare, 
it  is  believed  that  such  an  act  will  be  successful,  and  will 
represent  an  immense  force  for  communiiy  betterment.  If, 
on  the  other  hand,  any  of  the  above  group  see  in  health 
insurance  only  a  means  for  personal  gain  and  self  aggrandize- 
ment, failure  is  almost  certain  to  result. 


^ 


CHAPTEB  IX 
INDUSTRIAL  MBDICINB 

Industrial  medicine  has  been  defined  as  the  interpretation 
of  the  productive  capacity  of  an  industrial  plant  in  terms  of 
the  he^th  of  the  workers.  It  is  the  science  which  treats  of 
the  prevention  and  cure  of  industrial  injury  and  disease, 
increasing  productivity  through  the  promotion  of  better 
health. 

Twenty  years  ago  the  science  of  industrial  medicine  as  it 
is  known  today  was  almost  undreamed  of.  There  were,  it  is 
true,  a  few  firms  who  employed  a  "company  doctor,"  who  was 
on  call  for  emergencies  and  who  devoted  only  a  small  part 
of  his  time  to  the  company  work.  In  most  cases  when  an  acci- 
dent occurred  the  patient  was  sent  to  the  city  hospital  and 
the  responsibility  of  the  employer  ceased.  Most  employers 
kept  no  record  of  absence  because  of  sickness  and  little  or  no 
knowledge  was  available  as  to  the  cost  of  illness  either  to 
the  employer  or  employee.  Men  were  accepted  after  a  per- 
sonal interview  and  little  or  no  attempt  was  made  to  deter- 
mine the  physical  qualifications  of  the  applicants  for  tiie 
particular  job. 

With  the  development  of  the  larger  corporations  which 
necessitated  a  more  complete  83rstem  of  records  it  became  evi- 
dent that  the  company  had  an  investment  in  every  one  of  its 
employees  which  would  be  lost  in  the  event  of  disability.  It 
was  shown  that  there  was  a  certain  definite  cost,  which  could 
be  expressed  in  dollars  and  cents,  associated  with  tbe  train- 
ing of  every  new  employee.  It  was  also  found  that  the  mere 
absence  of  a  skilled  employee  from  work  even  for  a  few  days 

84 


,> 


INDUSTEIAL  MEDICINE  85 

aloved  down  production  and  canaed  a  certain  finaTiclal  loss. 
In  large  corporations  it  was  found  that  in  the  couiM  of  a 
year  their  losses  reached  enormoua  proportions.  ^ 

NEW  METHODS  NEEDED 

Some  of  the  more  progressive  organizations  such  as  the 
United  States  Steel  Company,  turned  to  the  medical  profes- 
sion for  relief.  It  was  realized  that  the  old  form  of  company 
doctor  had*  not  been  a  success  and  it  was  also  realized  that 
employers  a&  well  as  others  had  failed  to  grasp  the  full 
significance  of  the.  importance  of  industrial  health  work. 
Physicians'  salaries  were  inadequate,  their  oflSces  were  small 
and  inaccessible,  and  the  company  physician  had  little  official 
standing  in  the  corporation. 

The  attempt  to  correct  such  conditions  gave  rise  to  the 
new  conception  of  industrial  medicine  in  which  the  physician 
is  well  paid,  is  recognized  as  a  company  official,  and  devotes 
his  time  chiefly  to  prevention  of  injury  and  disease  rather 
than  cure.  The  medical  offices  should  be  commodious,  centrally 
located  and  fully  equipped  for  modern  scientific  methods. 
The  industrial  surgeon  must  be  able  to  analyze  the  cause  of 
accidents  and  indicate  the  need  for  modification  of  dangerous 
machines  or  mechanical  processes;  he  must  study  his  case 
records  and  indicate  necessary  public  health  measures  for  the 
correction  of  sanitary  defects;  he  must  study  the  employees 
and  the  positions  to  be  filled  and  attempt  to  make  the  man 
fit  the  job,  thus  increasing  production. 

It  may  be  said  to  the  credit  of  tbe  medical  profession  that 
they  have  fully  demonstrated  the  value  of  industrial  medicine 
from  a  business  standpoint.  Medical  departments  begun  as 
experiments  are  being  continued  as  paying  investments. 
While  the  movement  has  spread  rapidly  during  the  last  few 
years  it  may  be  said  to  have  only  just  begun.  Only  compara- 
tively few  of  the  larger  corporations  have  introduced  what 
may  be  considered  a  truly  comprehensive  system  of  health 
protection. 


86        THE  COMMUNITY  HEALTH  PEOBLEM 

Howeyer  during  the  last  few  yean  the  introduction  of  the 

principle  of  compensation  for  industrial  accidents  has  done 
'much  to  impress  upon  business  men  the  importance  of  early 
and  efficient  medi»d  care.  Companies  were  obliged  by  law 
to  insure  under  the  workmen's  compensation  acts  and  those 
having  an  undue  percentage  of  accidents  found  their  pre- 
miums raised  beyond  the  average  for  the  industry.  Insurance 
companies  found  that  their  costs  mounted  alarmingly  when 
no  provision  was  made  for  medioQ  care.  This  led  to  the 
establishment  of  surgical  first-aid  stations  in  large  plants 
with  the  employment  of  full  time  physicians  and  nurses. 
From  such  a  nucleus  a  large  number  of  more  or  less  well 
devebped  industrial  health  centers  have  been  developed. 

EXPENSES  PAID  BT  INDUSTRY 

The  essential  feature  of  the  industrial  health  movement,  in 
contradistinction  to  other  forms  of  health  activity,  is  that 
the  expenses  are  paid  in  the  main  by  the  industry  concerned. 
This  means  of  course  that  the  community  pays  the  bills  in 
the  end,  for  the  employer  spends  on  health  measures  the 
money  which  might  have  been  devoted  to  extra  wages.  But  it 
has  been  found  that  the  increase  in  wages  equivalent  to  the 
expenditures  for  health  promotion  does  not  materially  increase 
ei^er  community  health  or  company  production.  Health 
expenditures  by  industrial  organizations  must  be  compared  to 
taxes  for  good  roads  or  better  water  supply  which  reduce  the 
individual  income  but  act  positively  for  the  good  of  the 
community. 

The  per  capita  cost  of  industrial  medicine  varies  greatly 
according  to  the  work  done  and  the  character  of  the  industry. 
It  includes  part  of  the  premium  for  compensation  insurance 
and  in  addition  whatever  the  employer  may  decide  voluntarily 
to  spend  for  the  improvement  of  the  health  of  the  employee. 
Premiums  for  insurance  under  the  various  compensation  acta 
vary  in  the  different  states  and  in  the  various  occupations. 
In  New  York  the  rates  for  moderately  hazardous  occupations 


INDUSTEIAL  MEDICINE  87 

run  from  five  to  twenty  per  cent,  of  the  annual  payroll.  For 
non-hazardous  occupations  the  rates  may  be  as  low  as  two  or 
three  per  cent.  These  charges  include  a  part  of  cost  of  any 
system  of  industrial  medicine. 

Figures  from  a  large  number  of  corporations  show  that 
the  per  capita  cost  of  health  work  varies  from  less  than  two 
dollars  per  year  up  to  fifteen  or  twenty  dollars  per  year,  or 
even  higher,  th^  variation  being  due  largely  to  the  dMerence 
in  the  service  furnished. 


INDUSTRIAL  HEALTH  CENTER 

If,  as  a  result  of  the  study  of  various  existing  medical 
departments  in  large  corporations,  we  attempt  to  make  a 
composite  picture  of  industrial  health  activities  we  note  at 
once  that  the  health  center  forms  a  conspicuous  part  of  every 
plan.  Sometimes  it  is  called  the  dispensary,  sometimes  the 
clinic  and  sometimes  merely  the  doctor's  office,  but  in  all  it 
is  essentially  the  same,  the  headquarters  for  the  medical  work 
of  the  plant. 

Here  the  medical  director  should  ^ave  his  office  and 
records;  here  should  be  located  the  examining  rooms;  and 
close  by  should  be  the  office  of  the  visiting  nurses.  A  drug 
room,  a  laboratory,  an  x-ray  room  and  a  record  room  should 
all  form  part  of  this  central  group. 

In  some  plants  it  is  desirable  to  establish  branch  first-aid 
stations  in  buildings  located  some  distance  from  the  center. 
Many  large  plants  go  one  step  further  and  place  a  first-aid 
cabinet  in  every  department  so  that  it  is  immediately  avail* 
able  in  case  of  accident. 

In  connection  with  the  health  center,  arrangements  may 
be  made  for  hospital  facilities,  convalescent  accommodations, 
home  treatment  through  a  visiting  nurse  service,  conserva- 
tion of  children's  health  through  day  nurseries  and  other 
similar  measures,  and  for  co-operation  with  the  local  public 
hesl^  organization. 


88        THE  COMMUNITY  HEALTH  PBOBLEM 

PHYSICAL  EZAiaNATIOKS 

Physical  ezaminatioiu  shonld  be  made  of  all  applioaAts  for 
emplojrment.  The  examination  should  be  thorough  in  detail 
and  should  indicate  the  physical  condition  of  the  applicant 
and  the  necessity  of  treatment  of  physical  defects,  if  any. 
It  is  exceedingly  important  that  physical  examinations  be 
made  by  physicians  who  are  tactful  and  understanding  and 
who  undertake  to  help  the  applicant  to  find  a  suitable  posi- 
tion, avoiding  carefully  any  action  which  would  tend  to 
antagonize  the  worker.  The  physician  should  take  advantage 
of  this  opportunity  to  emphasize  his  sympathetic  co-operation 
with  the  worker  and  to  increase  the  mutual  personal  under- 
standing between  the  applicant  and  an  oflBcial  of  the  company. 

It  becomes  more  and  more  evident  that  few  should  be  dis- 
qualified because  of  physical  disability.  First,  those  who  have 
contagious  disease  and  are  dangerouB  to  other  workers  must 
of  course  be  excluded.  Second,  those  who  are  suffering  from 
disease  of  such  character  as  to  render  any  sort  of  work  dan- 
gerous to  their  health  must  be  turned  away.  But  further 
than  this  there  should  be  few  disqualifications.  The  old  idea 
of  disqualifying  a  man  because  of  the  loss  of  one  leg,  or  a 
simple  hernia,  or  deafness,  or  some  other  similar  disability, 
should  be  discarded.  It  should  be  part  of  the  duty  of  the 
examining  physician  to  indicate  the  kind  of  work  for  which' 
the  workman  with  a  physical  handicap  is  best  fitted  and  to 
make  every  effort  to  connect  the  ttiati  and  the  position. 

This  has  been  done  in  a  large  automobile  company  in  Detroit 
with  great  success.  Nearly  a  third  of  all  their  workmen  have 
flome  form  of  disability.  The  employment  director  and  the 
surgeon  make  a  careful  survey  of  the  plant  and  indicate,  for 
example,  what  positions  may  be  filled  by  one-legged  men. 
Similar  investigations  lead  to  the  classification  of  all  positions 
according  to  the  ph3^ical  requirements  with  the  result  that 
the  lame,  the  halt  and  the  blind  are  actuailv  placed  in  self- 
supporting  employment. 


INDUSTRIAL  MEDICINE  89 

ICBDIOAL  GABE  OF  BHPLOTBBS 

The  treatment  rooms  should  be  open  dnring  the  regol&r 
business  hours  and,  in  plants  which  are  large  enough,  a 
physician  should  always  be  in  attendance.  It  is  of  import- 
ance to  the  employer  that  every  patient  secure  prompt  and 
efScient  treatment  and  return  to  work  as  soon  as  possible.  In 
minor  injuries  a  small  dressing  and  light  bandage  which  will 
not  interfere  with  work  may  be  applied.  In  cases  of  slight 
indisposition  a  half  hour  rest  will  often  be  sufficient  for 
complete  recovery. 

In  complicated  cases,  x-ray  and  laboratory  examinations 
should  be  made  and,  if  necessary,  the  services  of  a  specialist 
should  be  provided.  When  there  are  several  surgeons  on 
the  staff  they  may  divide  the  work  so  that  one  may  specialize 
in  surgery,  another  specializes  in  diseases  of  the  nose  and 
throat,  while  others  specialize  in  some  of  the  other  special 
departments  of  medicine. 

A  nursing  service  is  a  necessary  adjunct  in  the  active 
medical  care  of  the  workers.  A  visiting  nurse  should  visit 
all  workers  who  report  sick  and  the  medical  director  should 
base  his  action  upon  the  nurses*  report.  Many  patients  may 
be  safely  cared  for  at  home  with  the  aid  of  an  efficient 
visiting  nursing  service. 

Dental  care  should  also  be  a  part  of  the  medical  serdce 
and  the  periodical  examination  of  the  teeth  should  be  encour- 
aged. Simple  fillings  may  be  made  without  charge  and  more 
complicated  bridge-work  given  for  cost. 

Shall  the  treatment  be  made  compulsory?  Many  workers 
object  to  compulsory  treatment  and  it  is  much  better  not  to 
insist  upon  it.  The  essential  factor  is  that  all  workers  in  the 
plant  must  be  included  in  the  health  plan.  Medical  advice 
must  be  made  available  to  them  all  but  there  is  no  necessity 
of  insisting  upon  treatment  for  this  is  apt  to  antagonize 
some  employees.  If  the  physicians  are  tactful  and  show 
sympathy  with  the  worker  there  will  be  little  difficulty.  Most 
employees  will  be  glad  to  accept  treatment  and  it  will  soon 


90        THE  COMMUNITY  HEALTH  PBOBLEM 

become  apparent  to  them  tliat  they  not  only  secnre  free  treat- 
ment at  the  plant  but  that  the  treatment  Ib,  as  a  rule,  at 
least  as  good  as  that  secured  from  private  sources. 

CONTRIBUTES  TO  WELFABE 

Industrial  medicine  is  today  closely  linked  to  industry.  Ji 
is  recognized  as  a  factor  in  continuous  employment  and  pro* 
duction.  It  makes  for  community  welfare  and  tends  to  pre- 
vent dissatisfaction  and  unrest. 

It  is  closely  related  to  the  communily  health  movement 
and,  when  seen  at  its  best,  has  seemed  to  come  nearest  to  rep- 
resenting a  practical  form  of  sickness  prevention  and 
health  control  applicable  with  slight  modification  to  the 
entire  community.  Its  main  disadvantage  is  that  it  is  dif- 
ficult to  adapt  it  to  the  needs  of  the  small  employer.  As  a 
rule  at  least  500  employees  are  required  to  justify  the  forma- 
tion of  a  medical  department.  However,  if  industry  has 
shown  us  how  much  can  be  accomplished  along  health  lines 
by  a  business-like  medical  service,  it  should  be  possible  for 
the  rest  of  us  to  find  some  way  of  adapting  a  similar  service 
to  the  needs  of  the  general  community. 

INSUSANCB 

In  many  cases  industrial  organizations  have  made  sickness 
and  life  insurance  available  for  their  employees  at  a  low 
price.  This  is  accomplished  through  what  is  known  as  group 
insurance.  In  insurance  of  this  type  a  large  number  of  em- 
ployees are  insured  in  a  group  at  a  flat  rate.  The  premiums 
may  be  paid  entirely  by  the  employer,  or  entirely  by  the 
employee,  or  they  may  share  the  expense.  In  any  event  the 
employer  makes  the  actual  payment  of  the  premium  in  a  lump 
sum  calculated  from  the  pay  roll.  This  reduces  the  charges 
for  collection  so  that  insurance  of  this  type  can  be  sold  very 
much  cheaper  than  when  sold  to  individuals. 

Life  insurance  is  issued  in  policies  of  from  one  to  five 
thousand    dollars,   the    larger    amounts    being    carried    by 


INDUSTRIAL  MEDICINE  91 

employees  of  several  years  service.  Sickness  insurance  with 
a  weekly  benefit  is  usually  written  for  a  fixed  period  of  from 
13  to  52  weeks.  However  in  some  cases  the  insurance  may 
be  based  upon  the  salary,  payable  over  a  period  of  several 
years.  It  is  ordinarily  payable  only  during  complete  dis- 
ability. 

The  Metropolitan  Life  Insurance  Company  insures  its  own 
employees  against  sickness  disability  practically  for  life.  For 
the  first  twenty-six  weeks'  illness,  two-thirds  of  the  salary  is 
paid.  Prom  the  twenty-seventh  week  until  the  end  of  the 
fifth  year  one-half  of  the  original  benefit  is  paid  and  from 
this  time  until  the  employee  reaches  the  age  of  65,  he  receives 
one-quarter  of  the  original  benefit. 

The  same  company  in  its  annual  report  on  welfare  work 
makes  the  following  statement: 

''The  company  feels  that  it  is  conducting  a  social  laboratory 
in  the  care  that  should  be  given  working  people.  It  has  felt 
furthermore  that  if  it  could  show  iihe  value  of  its  efforts  to 
other  employers  it  would  benefit  its  millions  of  policy-hold- 
ers at  present  engaged  in  industries  of  all  kinds.  If  it  could 
emphasize  to  the  employers  of  these  policy-holders  the  value 
of  proper  working  conations  it  would  be  able  to  secure  for 
all  workers  longer  lives  and  increased  health." 

This  insnranoe  company  which  has  had  a  long  experience 
in  industrial  insurance,  and  close  contact  with  industrial 
workers,  has  found  that  welfare  work  among  its  own  em- 
ployees pays  and  it  advises  other  employers  to  adopt  similar 
measures.  But  it  points  out  that  health  and  welfare  work 
must  be  given  in  addition  to  wages  and  not  a  substitute  for 
them ;  that  welfare  work  is  not  a  substitute  for  opportunities 
for  development  and  advancement ;  and  that  it  must  not  inter- 
fere with  the  right  of  the  employee  to  live  his  or  her  life 
without  undue  interference. 


CHAPTEB  X 


STATE  MBDICINB 


For  years  many  clear  thinkers  have  insisted  that  the  com- 
ing of  a  state  medical  service  was  inevitable.  In  England 
progress  toward  this  end  has  been  more  rapid  than  in  Amer- 
ica. Some  twenty  odd  years  ago  Havelock  Ellis  in  his  book, 
"The  Nationalization  of  Health,"  snggested  the  need  of 
national  supervision  of  health  with  a  well  organized  medical 
service  based  upon  conminnify  needs  and  under  national 
controL 

In  1917  he  repeated  his  earlier  view  as  to  the  inadequacy 
of  the  present  S3ratem  of  private  practice  and  voiced  the  need 
of  a  different  form  of  medical  service  as  follows:  'It  is 
inevitable"  he  says  "that  we  should  some  day  have  to  face 
the  problem  of  medical  reorganization  on  a  social  basis. 
Along  many  lines  social  progress  has  led  to  the  initiation  of 
movements  for  the  improvement  of  public  health.  But  they 
are  still  incomplete  and  imperfectly  co-ordinated.  We  have 
never  realized  that  the  great  question  of  health  cannot  be  left 
to  municipal  tinkering  and  to  the  patronage  of  Bumbledom. 
The  result  is  chaos  and  a  terrible  waste,  not  only  of  what  we 
call  *hard  cash*  but  also  of  sensitive  flesh  and  blood.  Health, 
thero  cannot  be  the  slightest  doubt,  is  a  vastly  more  funda- 
mental and  important  matter  than  education,  to  say  nothing 
of  such  minor  matters  as  the  post  office  or  telephone  system. 
Yet  we  have  nationalized  these  before  even  giving  a  thought 
to  the  nationalization  of  healtL" 

In  1913,  England  introduced  a  comprehensive  system  of 
health  insurance  and  recently  there  has  been  organized  a 
Ministry  of  Health.    If  anything,  the  trend  toward  a  state 

92 


STATE  MEDICINE  93 

'medical  service  has  been  increased  rather  than  diminished 
during  the  war. 

In  America  an  cttempt  which  was  made  several  years  ago 
to  establish  a  Federal  Department  of  Health  with  a  Secre- 
tary of  Health  at  the  head  was  unsuccessful  and  up  to  the 
present  none  of  the  states  has  adopted  the  principle  of 
health  insurance  or  other  form  of  state  controlled  medicine. 

America  is  proceeding  more  slowly  and  conservatively  than 
is  England  in  matters  which  have  to  do  with  public  health. 
Possibly  an  explanation  for  this  is  found  in  comparison 
of  the  living  conditions  of  the  two  countries.  Health  is 
largely  influenced  by  living  conditions  and  such  conditions 
are  apt  to  become  less  and  less  sanitary  as  the  population 
increases  .  In  cities  the  complexity  of  all  problems  of  sani- 
tation is  greatly  increased  and  the  evil  effects  of  high  disease 
rates  are  more  plainly  evident  than  in  rural  communities. 
Moreover  the  close  relation  of  employer  and  employee  in  in- 
dustrial communities  tends  to  emphasize  the  money  loss 
caused  by  physical  disability.  As  a  consequence,  in  a  country 
like  England,  which  contains  many  large  industrial  cities 
where  there  is  much  overcrowding,  the  health  problem  looms 
much  larger  than  it  does  in  the  United  States  where  there 
is  less  crowding  and  less  evidence  of  defective  sanitation. 

In  rural  communities,  the  evil  effects  of  disease  are  not  so 
apparent  as  in  the  larger  cities  so  that,  even  in  the  United 
States,  public  health  efforts  have,  as  a  rule,  been  much  bet- 
ter developed  in  large  municipalitieB  than  in  the  outlying 
districts. 

STATE  MEDICINE  AND  PRIVATE  PEACTICB 

It  has  been  stated  that  the  system  under  which  the  private 
practice  of  medicine  is  now  carried  on  is  out  of  date,  and 
that  it  fails  to  answer  the  needs  of  our  time.  This  state- 
ment is  substantiated  by  a  variety  of  reasons  which  are  slowly 
becoming  more  apparent  to  all. 

Medicine  today  has  outgrown  the  capacity  of  the  private 


94        THE  COMMUNITY  HEALTH  PBOBLEM 

practitioner.  In  order  to  give  his  patient  reasonably  adequate 
medical  treatment  according  to  modem  standards,  the  physi- 
cian must  not  only  have  a  general  knowledge  of  medicine 
bait  must  be  qnalified  as  an  erpert  in  a  number  of  special- 
ties as  welL  He  must  not  only  acquire  this  knowledge  by 
years  of  effort,  but  he  should  also  have  the  elaborate 
mechanical  equipment  which  is  now  necessary  for  efficient 
diagnosis  and  treatment.  Such  equipment  may  be  found  in 
great  hospitals,  where  it  is  available  for  the  benefit  of  the 
poor  but  it  is  far  beyond  the  means  of  the  average  practi- 
tioner. Failing  snch  expert  knowledge  and  elaborate  equip- 
ment, if  he  desires  to  give  the  best  to  his  patient,  the  physi- 
cian must  refer  a  large  proportion  of  his  practice  to  special- 
ists. As  a  result  of  the  gradual  disappearance  of  his  practice 
the  ambitious  physician  soon  specializes  himself  so  that  he 
may  feel  qualified  in  at  least  one  subject  and,  as  a  result, 
the  general  practitioner  disappears. 

But  the  most  weighty  reason  for  the  advance  of  the  national 
idea  in  medicine  in  contradistinction  to  the  further  develop- 
ment of  individual  practice  is  that  the  present  system  is 
based  upon  Ute  cure  of  disease  rather  than  its  prevention. 
The  total  spent  for  the  cure  of  disease  is  enormous;  the 
money  spent  for  prevention  is,  in  comparison,  a  sum  of 
insignificant  proportiona. 

Today  the  student  receives  better  instruction  in  the  science 
of  medicine  than  ever  before.  Magnificently  equipped  insti- 
tutions are  endowed  so  that  medical  education  may  be  secured 
at  a  minimum  expense,  and  educational  requirements  have 
•increased  so  that  a  medical  degree  is  obtained  only  after 
years  of  arduous  training.  When  the  young  physician  fresh 
from  college  tries  to  apply  his  science  to  practice  he  finds 
that  the  expense  involved  in  the  care  of  disease  deprives  a 
great  number  of  people  of  the  benefits  of  modem  treatment. 

The  question  which  arises  in  the  mind  of  the  recent 
graduate  is  whether  there  is  not  some  method  whereby  the 
benefits  of  modem  treatment  could  be  made  available  to  all 


STATE  MEDICINE  95 

at  a  cost  within  the  limits  of  Teason.  In  answer  to  this  query 
those  who  advocate  the  complete  socialization  of  medicine 
point  to  the  slow  increase  of  the  powers  and  activities  of 
the  pnblic  health  authorities,  to  the  enactment  of  the  Work- 
men's Compensation  Act,  to  the  agitation  for  health  insur- 
ance in  some  form,  and  to  the  establishment  of  a  Ministry 
of  Health  in  England,  as  evidences  of  a  gradual  change  which 
is  taking  place  leading  eventually  to  state  medicine. 

State  medicine,  as  the  term  is  ordinarily  used,  indicates 
the  complete  control  of  health  of  the  individual  by  govern- 
mental authorities.  In  practice  such  a  system  would  probably 
work  out  along  the  same  general  lines  as  education.  Every 
citizen  would  be  entitled  to  free  treatment  if  he  desired  it. 
Hospitals  and  sanitoria  wotdd  be  conveniently  established 
and  physicians  would  be  either  directly  or  indirectly  in  the 
employ  of  the  government.  Treatment  would  not  be  com- 
pulsory, except,  aa  at  present  for  contagious  diseases,  and 
patients  desiring  extra  personal  attention  would  be  treated 
just  as  at  present,  by  private  physicians. 

PLAN"    FOB    UNIVEBSAL    STATE    SERVICB 

If,  in  the  United  States,  there  were  organized  a  truly  com- 
prehensive system  of  state  medicine,  along  what  lines  would 
such  an  organization  develop  and  of  what  would  it  consist? 

In  the  first  place  there  would  be  required  a  United  States 
Department  of  Health  with  a  Secretary  of  Public  Health. 
This  department  would  include  the  present  United  States 
Public  Health  Service,  now  under  the  Treasury  Department, 
the  Board  for  Child  Welfare  now  under  the  Department  of 
Labor,  the  Indian  Medical  Service  now  under  the  Depart- 
ment of  the  Interior  and  the  various  other  medical  activities 
under  the  Federal  Government.  The  duties  of  such  a  depart- 
ment would  include  the  care  of  medical  problems  which  arise 
in  connection  with  national  needs,  all  questions  which  have 
to  do  with  immigration  or  emigration  and  the  health 
aspects  of  interstate  commerce.     In  addition  the  Federal 


96        THE  COMMUNITY  HEALTH  PROBLEM 

Department  of  Health  would  act  to  correlate  the  health  work 
of  the  various  states. 

State  medicine,  as  organized  within  state  limits,  would  be 
divided  according  to  the  nature  of  its  work  somewhat  as 
followB: 

(a)  A  division  of  preventive  medicine. 

(b)  A  division  of  hospitalization. 

(c)  A  division  of  medical  treatment. 

(d)  A  research  division. 

(e)  A  division  of  medical  education. 

Of  course  such  a  classification  is  entirely  arbitrary  and 
would  be  subject  to  considerable  variation.  Sanitation,  child 
welfare,  the  prevention  of  accidents,  social  hygiene  and  many 
other  similar  subjects  would  fall  naturally  into  one  or  the 
other  of  the  above  divisions. 

A  state  system  would  pre-suppose  a  headquarters  and  ad- 
ministration office  in  one  of  tibe  larger  cities  of  the  state, 
which  would  control  the  general  policy  of  the  state  medical 
service  just  as  the  Surgeon-GeneraPs  office  controls  the  poli- 
cies of  the  Medical  Department  in  the  United  States  Army. 
There  would  be  established  in  various  localities  of  not  more 
than  25,000  inhabitants  a  medical  center  with  facilities  for 
hospitalization,  laboratory  examinations  and  consultations 
with  specialists.  Possibly,  for  purposes  of  administration,  it 
might  be  desirable  to  group  several  of  these  centers  into  a 
single  administrative  unit.  Physicians  would  be  constantly 
in  attendance  at  these  centers  and  visiting  nurses  would  be 
available  for  work  in  the  district.  The  services  of  the  physi- 
cians and  nurses  would  be  available  for  rich  and  poor  alike. 
All  divisions  of  the  State  Department  of  Health  would  of 
course  be  represented  at  each  center  and  each  center  should 
be  made  as  nearly  as  possibly  an  autonomous  unit. 

Such  a  center  would  require  from  ten  to  twenty  physicians, 
including  specialists,  with  possibly,  an  equal  number  of 
nurses  and  there  would  be  in  the  entire  state  of  New  York 
possibly  in  the  neighborhood  of  three  hundred  such  centers. 


STATE  MEDICINE  97 

PhysidaLs  practicing  the  various  specialties  would  be  avail- 
able at  eadi  center  and  patients  treated  in  their  homes  would 
be  cared  for  by  physicians  assisted  by  visiting  nurses.  A 
clerical  force  would  be  available  to  relieve  the  professional 
staff  of  most  of  the  purely  clerical  duties. 

PERSONNEL 

The  personnel  of  such  a  system  would  of  necessity  be  re- 
cruited from  the  physicians  and  nurses  practicing  in  the 
state.  It  is  claimed  by  many  that  the  better  class  of  physicians 
would  not  enter  into  any  such  scheme  and  that  as  a  conse- 
quence it  would  surely  result  in  failure.  Without  the 
enthusiasm  and  co-operation  of  the  physicians  and  surgeons 
who  would  practice  under  such  a  system  the  service  would 
be  greatly  handicapped  but  it  is  the  conviction  of  the  advo- 
cates of  state  medicine  that,  if  the  service  were  made 
attractive,  if  the  salaries  were  adequate,  and  if  the  physicians 
were  offered  a  career  as  public  health  ofiBcials,  a  satisfactory 
medical  service  could  be  furnished  to  the  inhabitants  of  the 
state  as  a  whole  at  a  cost  considerably  less  than  under  the 
present  system. 

The  question  might  reasonably  be  asked  as  to  the  ultimate 
effect  of  such  a  system  on  private  practice.  There  is  no 
doubt  that  private  practice  would  be  somewhat  decreased  but 
it  is  doubtful  if  the  decrease  would  be  appreciable  at  first. 
In  spite  of  the  fact  that  aE  persons  would  be  entitled  to  free 
treatment,  the  rich,  and  to  a  certain  extent  those  moderately 
well-to-do,  would  continue  to  employ  private  physicians  and 
specialists  as  heretofore.  The  man  who  could  afford  the  ex- 
pense would  probably  choose  to  occupy  a  private  room  in  the 
hospital,  and  many  persons  would  prefer  not  to  accept  free 
treatment  from  the  State.  The  ultimate  result  would  depend 
upon  the  quality  of  service  offered  and  possibly  in  time  private 
practice  of  medicine  would  decrease,  but  it  is  improbable 
that  the  time  would  ever  come  when  there  would  not  be  a 
large  number  of  persons  who  preferred  to  pay  for  medical 


98        THE  COMMUNITY  HEALTH  PROBLEM 

attention.  State  medicine  is  not  an  attempt  to  secure  proper 
treatment  for  the  rich.  It  is  intended  primarily  for  the  pre- 
vention of  disease  and  for  the  benefit  of  those  who  are  unable 
to  pay  for  treatment  under  the  present  system. 

To  the  best  of  my  knowledge  and  belief,  a  state  medical 
service  as  outlined  above  has  never  been  carried  out  on  a 
large  scale.  Health  insurance  as  it  is  seen  in  some  of  the 
European  countries  is  under  government  control  and  closely 
approaches  state  medicine,  but  could  not  properly  be  called 
public  medicine  in  the  same  sense  in  which  we  use  the  term 
in  referring  to  public  education. 

Military  medicine  somewhat  approaches  the  ordinary  con- 
ception of  a  state  system  of  medicine,  and  any  contemplated 
state  service  might  gain  a  considerable  amount  of  information 
by  a  study  of  the  organization  and  administration  of  the 
Army  Medical  Department,  but  there  are  too  many  other 
factors  is  military  medicine,  such  as  mobility  of  medical 
units,  transportation,  battle  casualties,  etc.,  to  make  it 
applicable  to  civilian  needs  without  extensive  changes. 

What  is  needed  today  is  the  scientific  application  to  the 
problems  of  civilian  life  of  what  the  physician  has  already 
learned  by  military  experience.  Competition  in  the  practice 
of  medicine  has  no  place  in  military  service  and  should  have 
little  if  any  place  in  civilian  practice.  Co-operation  whether 
it  be  for  education,  public  welfare  or  better  health  will 
accomplish  more  for  the  citizens  of  a  community  than  can 
possibly  be  expected  from  any  system  based  largely  npon 
individual  competition. 


CHAPTER  XI 
HEALTH  CENTERS 

During  recent  years,  activated  largely  by  the  growing  in- 
terest in  community  health  an  effort  has  been  made,  in  widely    \ 
scattered  localities,  to  increase  the  eflBciency  of  the  various 
local  health  agencies  through  the  organization  of  community     i 
health  centers.     The  development  of  the  health  center  idea     j 
has^^been  gradual  and  more  or  less  spontaneous,  originating     j 
coincidently   in   several   widely   separated   communitiea    at     \ 
approximately  the  same  period.    Health  centers  were  of  pre- 
war origin  but  their  growth  was  greatly  accelerated  during 
the  war  period,  due  largely  to  the  enforced  concentration  of 
effort  in  order  to  overcome  so  far  as  possible  the  shortage  of 
medical  service,  a  result  of  the  absence  from  the  community 
of  a  large  number  of  practicing  physicians. 

It  is  not  improbable  that  health  centers  were  the  natural"^ 
outgrowth  of  the  dispensary  and  that  they  were  originally  / 
formed  in  cities  too  small  for  the  establishment  of  elaborate 
dispensaries  and  public  health  laboratories,  being  instituted  I 
in  an  effort  to  afford  relief  and  treatment  for  certain  needy  \ 
members  of  the  community,  especially  the  tuberculous.  ^ 

BED  CBOSS  HEALTH  CENTEBS 

After  the  war  the  American  Red  Cross  undertook  the 
establishment  of  health  centers  as  a  peace-time  activity.  They 
describe  a  health  Center  •  as '**a  physical  center  of  some  pro- 
ductive form  of  co-ordination  of  the  health  agencies  and 
activities  of  a  community."  The  plan  as  announced  was 
not  the  introduction  of  a  new  organization  but  the  establish- 
metit  of  a  central  agency  by  means  of  which  team  work  i 
could  be  secured. 

In  a  preliminary  survey  made  by  the  Red  Cross  during  the 
latter  part  ol  1919  there  were  secured  records  of  79  existing 

99 


100      THE  COMMUNITY  HEALTH  PROBLEM 

health  centers  scattered  over  the  United  States.*  Li  seven  of 
the  'cIEes  there  was  more  than  one  center,  so  that,  in  all, 
forty-nine  communities  were  represented.  This  number  is,  no 
doubt,  very  incomplete  because  many  centers,  being  more  or 
less  spontaneous  in  origin,  are  not  on  record  as  such  and,  in 
some  places,  the  functions  of  a  health  center  are  taken  on, 
in  part  at  least,  by  existing  institutions  such  as  hospitals 
or  dispensaries,  and  are  so  classified.  In  addition  to  the 
existing  health  centers,  the  Eed  Cross  found  that  there 
were  thirty-three  new  centers  definitely  started  in  tweniy- 
eight  communities,  and  many  others  planned  for  early 
development.  The  Social  Unit  experiment,  which  is  fully 
described  in  another  chapter,  is  in  many  respects  a  form  of 
health  center.  In  New  York  City  the  Department  of  Health 
has  established  tuberculosis,  industrial,  and  child  welfare 
clinics,  which  represent  in  a  somewhat  modified  form  health 
centers  for  certain  districts  of  the  city. 

Analysis  of  the  existing  and  proposed  centers  studied  by 
the  Red  Cross  shows  that  at  the  time  of  the  report,  (pub- 
lished in  March  1920)  thirty-three  were  administered 
entirely  by  the  public  authorities,  twenty-seven  were  under 
private  control  and  sixteen  were  under  combined  public  and 
private  control.  The  Eed  Cross  was  concerned  in  nineteen 
instances. 

There  was  considerable  variance  in  the  work  and  aims  of 
the  existing  health  centers.  In  forty  communities  having 
health  centers  in  operation,  thirty-seven  contain  clinics  of 
some  type,  thirty-four  do  visiting  nursing,  twenty-nine  do 
child  welfare  work  and  twenty-seven  do  anti-tuberculosis 
work.  Twenty-two  have  venereal  clinics,  fourteen  have  dental 
clinics  and  eleven  have  eye,  ear,  nose  and  throat  clinics.  In 
only  ten  are  there  laboratories  and  in  only  nine  milk  stations. 

WHAT  IS  MEANT  BY  A  HEALTH  CENTER 

It  is  evident  from  the  above  that  the  health  center  does 

•TobeT,  James  A.:  The  Health  Center  MoTcment  In  the  United  States. 
Ih«  Modern  Hospital,  March.  1920. 


HEALTH  CENTEES  101 

not  represent  a  fixed  plan  for  the  improvement'  of  health  but 
varies  considerably  according  to  the  needs  of  the  community, 
the  available  funds,  and  the  ideas  of  its  originators.  In 
general,  it  means  a  building,  or  portion  of  a  building,  cen- 
^ally 'located  where  various  more  or  less  closely  related  wel- 
fare and  health  activities  are  carried  out.  The  grouping 
together  of  various  health  activities  may  be  expected  to  make 
for  better  co-ordination  and  to  prevent  duplication  of  effort.* 

In  some  cases  the  term  "health  center**  is  used  to  apply 
to  two  or  more  municipal  hospitals  and  laboratories  located 
in  a  group  and  under  the  control  of  the  public  health  authori- 
ties. This  is  not,  however,  the  sense  in  which  the  word  is 
ordinarily  used  in  speaking  of  the  health  center  movement. 

In  New  York  State  the  health  center  movement  is  expand- 
ing rapidly.  In  general,  the  plan  in  the  smaller  cities  has 
been,  apparently,  to  secure  a  building  where  the  local  health 
officer  could  have  his  headquarters,  and  to  house  in  the  same 
building  the  visiting  nursing  service,  and  various  other  health 
organizations  located  in  the  community. 

Theoretically  two  forms  of  health  centers  are  possible,  de- 
pending upon  the  extent  of  medical  treatment,  which  may  be 
limited  or  unlimited.  The  first,  and  the  one  which  is  most 
commonly  seen  imder  present  conditions,  would  possibly  in- 
clude: The  public  hesdth  workers;  the  Red  Cross;  the  dis- 
trict nurses;  and  all  charitable  organizations  interested  in 
public  welfare.  Physicians  may  hold  clinics,  limiting  treat- 
ment at  the  center  to  those  patients  unable  to  pay  for  the 

'Health  Centers  are  described  by  the  American  Red  Cross  In  a  special 
circular  of  information  as  follows:  "A  health  center  Is  the  physical 
headquarters  for  the  pubUc  health  work  of  a  community.  As  snch,  It  Is 
the  practical  and  concrete  expression  of  the  Interest  of  the  community 
In  the  health  of  Its  Inhnbitauts.  It  constitutes  a  business-like  way  of 
associating  health  activities,  both  public  and  private,  under  one  roof,  in 
dally  touch  and  in  complete  mutual  understanding.  The  health  center 
thus  represents  the  latest  step  in  the  evolution  of  community  health 
work,  and  answers  the  demand  for  efficient  conservation  of  effort  Im 
bringing  together  important  but  hitherto  Independent  health  campaigns, 
such  as  those  for  the  prevention  of  tubercoloals.  venereal  dueases, 
mental  diseases,  inrtustrlfil  dlfenpps,  and  nbove  all  the  vitally  necessary 
modern  effort  for  the  conservation  of  child  life.  In  turn,  it  offers  new 
possibilities  of  properly  relating  these  volunteer  activities  to  the  official 
nealth  work  of  the  city,  county,  state,  and  Federal  aothorltiea."  (A.' 
Circular  1000,  September,  1010.) 


102      THE  COMMUNITY  HEALTH  PBOBLEM 

semoes  of  a  private  physician.  The  work  would  cooBist 
laigely  in  diBease  prevention  and  education.  In  the  second 
plan  the  health  center  will  represent  the  medical  center  of 
the  conunTiniiy  for  the  unlimited  treatment  of  disease  as 
well  as  for  prevention  and  education.  Under  such  a  plan  phy- 
sicians would  be  on  duty  at  all  times,  the  services  of  special- 
ists would  be  available  when  required,  and  every  patient  ap- 
plying would  be  entitled  to  treatment  whether  ''able  to  pa/' 
or  not.  Laboratory  facilities  and  x-ray  apparatus  should  be 
a  part  of  the  equipment  and  there  might  be  a  staff  of  physi- 
cians and  visiting  nurses  to  care  for  patients  in  their  hmnes.^ 

How  a  health  center  is  to  be  financed  is  a  difi&cult  ques< 
tion.  One  carved  out  according  to  the  second  plan  is  based 
essentially  upon  what  has  come  to  be  known  as  "group  medi- 
cine" which  is  acknowledged  as  more  scientific  and  efficient 
than  the  general  run  of  private  practice.  Such  a  health  cen- 
ter might  function  either  under  the  public  health  authori- 
ties, health  insurance,  industrial  medicine,  or  under  one  of 
the  various  local  or  national  voluntary  organizations. 

Any  form  of  health  center  which  does  not  take  into  con- 
sideration the  care  of  the  large  number  of  cases  of  sickness 
which  now  receive  inadequate  treatment,  will  fall  short  of, 
accomplishing  the  maximum  benefit  for  public  health.** 

INDUSTBIAL  CENTERS 

So  far  as  is  known  none  of  the  centers  at  present  in  exist- 
ence give  complete  medical  service  to  all  members  of  the 
community.  The  nearest  approach  to  such  a  plan  is  found 
in  certain  industrial  communities  where  a  large  industry  has 
established  an  industrial  health  clinic  for  the  care  of  its  em- 
ployees. In  some  cases  industrial  clinics  have  reached  a  high 

*  A  plan  whlcb  closely  approacbes  this  has  been  proposed  for  New 
Tork  and  a  bill  to  this  end  was  introdaced  in  the  1820  session  of  the 
State  Leffislatare. 

••Since  the  above  was  written  a  plan  has  been  proposed  to  divide 
medical  service  in  England  into  ^oups  of  "primary  bealth  centers" 
under  the  control  of  local  physicians  and  "secondary  health  centers" 
where  treatment  by  specialists  will  be  available.  It  is  stated  that  if 
this  plan  is  carried  ont  it  will  completely  revolutionize  medical  practice. 


HEALTH  CENTEES  103 

degree  of  devetopment,  with  well  equipped  offices  and  several 
physiciana  (indudiDg  specialists)  on  duty.  Visiting  nurses 
are  employed  and  complete  records  are  kept  of  illness 
occurring  among  employees. 

The  work  of  the  industrial  physician  is  divided  between 
preventive  and  curative  medicine.  Prevention  of  accidents 
as  well  as  industrial  diseases  is  included  in  his  duties.  He 
must  also  include  in  preventive  medicine  the  elimination  of 
those  more  or  less  ill  defined  conditions  which  are  caused  by 
monotony  and  fatigue.  He  watches  not  only  the  sick  rate 
but  bonus  rate  and,  where  bonuses  are  persistently  not  earned, 
he  must  search  for  a  physical  reason  for  this  failure.  He 
must  assist  the  man  with  a  physical  or  mental  disabiliiy  to 
secure  proper  employment ;  he  must  weed  out  the  misfits ;  he 
must  properly  interpret  the  effecCs  of  ill  health  upon  produce 
tion;  and  he  must  interest  himself  generally  in  the  welfare 
of  the  employees. 

Under  curative  medicine  the  industrial  physician  is  re- 
quired to  treat  injury  and  disease  from  the  standpoint  of 
economic  loss  to  the  individual  and  industry,  as  well  as 
from  the  standpoint  of  scientific  medicine.  He  must  realize 
that  a  healthy  body  is  necessary  for  efficient  manual  labor  and 
that  health  is  one  of  the  most  valuable  assets  of  the  com- 
munity.    (See  also  Chap.  IX,  p.  84.) 

In  the  best  type  of  modem  industrial  health  center  the 
community  health  problem  has  been  met  practically  by  the 
following  provisions:  (a)  Hedical  care  both  at  home  and  in 
the  shop;  (b)  Visiting  nursing  service;  (c)  Hospital  care 
either  at  the  company  hospital  or  a  nearby  general  hospital; 
(d)  Insurance  benefits  for  disability  and  death;  (e^  Becon- 
struction  and  rehabilitation  of  cripples;  (f)  Prevention  of 
accident  and  disease — ^industrial,  personal  and  social;  (g) 
Welfare — including  housing,  child  weKare,  amusements, 
exercise,  etc. 

Industrial  health  centers,  unlike  some  other  health  activi- 
ties, are  not  largely  theory  with  little  or  no  practice.  They  are 


104      THE  COMMTJNITy  HEALTH  PROBLEM 

practical  from  beginning  to  end.  They  are  started  not  as 
charity  but  because  they  pay  and,  inasmuch  as  they  arise 
because  of  community  needs,  they  must  be  paid  for  entirely 
by  the  combined  resources  of  the  employer  and  employee,  thus 
in  the  end  being  paid  for  by  the  community  which  they  serve. 
They  represent  excellent  examples  for  other  communities  to 
follow,  for  it  is  a  self  evident  fact  that  in  the  end  every 
health  activity  should  be  supported  by  the  community  it  serves. 
Temporary  help  may  be  given  by  the  Eed  Cross,  by  private 
charity  or  by  the  Federal  or  state  government  but  such  help 
is  only  a  sort  of  demonstration,  a  try-out.  In  a  wide  move- 
ment for  better  health  every  representative  community  must 
be,  to  a  large  extent  at  least,  self-supporting. 

HOSPITALS 

Health  centers,  whether  industrial,  public,  or  private  in 
origin,  may  be  aflfiliated  with  the  community  hospital  and 
patients  discharged  from  hospitals  may  be  kept  under  pro- 
fessional observation  by  the  staff  of  the  health  center.  Every 
effort  should  be  made  to  co-ordinate  the  work  of  the  center 
and  the  hospital  so  that  expenditure  of  the  least  energy  will 
secure  the  greatest  results.  In  many  cases  a  community  hos- 
pital may  be  made  a  part  of  the  health  center  and  this  is 
especially  true  in  villages  and  the  smaller  cities. 

ALAMEDA    COUNTY   HEALTH    CENTEB 

One  of  the  best  equipped  of  the  recently  established  health 
centers  is  located  in  Alameda  County,  California.  The  local 
committee  have  set  forth  their  conception  of  the  aims  of  a 
health  center  and  the  reasons  for  its  existence  as  follows:* 

"The  health  center  is  defined  as  an  institution  which  co- 
ordinates the  public  health  work  of  the  community  in  a  cen- 
trally located  building  available  to  every  man,  woman  and 
child.  It  conducts  clinics — surgical,  medical  and  dental — 
with  the  aim  of  making  hospital  care  unnecessary.    It  pro- 

•AbBtracted  In  the  American  Journal  of  Pnbllc  Health.  March,  1920. 


HEALTH  CENTEKS  105" 

vides  health  instruction  in  personal  hygiene  to  both  children 
and  adults  by  means  of  popular  lectures,  lantern  slides  and 
the  distribution  of  literature.  It  oSers  instruction  in  mater- 
nity and  child-welfare,  thus  reducing  infant  mortality.  It 
serves  as  a  clearing  house  for  all  public  health  infonnatioUj 
^hus  effecting  a  closer  co-operation  among  hospitals.  It 
'divides  the  community  into  health  districts,  each  with  a  defis 
nite  health  organization  which  can  instantly  be  mobilized  in 
case  of  threatened  epidemic.  It  prevents  overlapping,  dupli- 
cation and  waste  because  it  co-ordinates  aU  health  and  relief 
organizations." 

From  the  same  spurce  we  are  given  ten  reasons  why  ^verj. 
community  should  establish  and  support  a  health  center, 
TEey~are:  (1)  Tt  promotes  community  health;  your  own 
safety  depends  on  healthful  surroundings.  (2)  It  reduces- 
loss  of  income  caused  by  sickness;  earning  power  rests 
on  health.  (3)  It  decreases  infant  mortality.  (4)  It  fosters 
health  education;  one  school  child  out  of  two  is  defective]" 
three  out  of  four  have  defective  teeth.  (5)  It  reduces  labor 
turn-over,  making  fewer  hands  to  train,  (6)  It  mobilizes  the 
forces  of  public  health  and  welfare.  (7)  It  increases  wealth. 
A  healthy  communily  is  a  good  banking  community.  (8)  It 
prevents  epidemics.  (9)  It  protects  the  home;  a  healthy 
home  produces  a  more  eflBcient  worker,  a  more  contented  cit- 
izen. (10)  Public  health  is  purchasable;  a  community  to  a 
large  extent  can  determine  its  own  death  rate. 

It  is  understood  that  the  Alameda  County  Board  of  Super- 
visors have  made  a  liberal  appropriation  to  carry  out  the 
health  program.  More  than  two  thousand  cases  a  month  have 
been  treated  since  the  establishment  of  the  center  and  the 
experiment  gives  every  promise  of  success. 

In  1920,  legislative  action  was  started  in  New  York  for 
the  state-wide  application  of  the  health  center  principle.  This 
movement  had  the  endorsements  of  the  State  Charities  Aid 
Association  and  the  State  Commissioner  of  Health.  The  bill, 
known  as  the  Sage-Machold  bill,  proposed,  in  brief,  a  health 


106      THE  COMMUNITY  HEALTH  PBOBLEM 

center  in  every  commnnity  consisting  of  a  hospital,  a  labors- 
toxy,  and  a  dispensary,  under  the  control  of  a  local  health 
board  with  the  advice  and  approval  of  the  state  board  of 
health.  A  full  time  medical  director  and  paid  attending 
physicians  and  nurses  were  to  furnish  medical  care  at  a 
reasonable  cost,  or  free,  when  necessary,  to  all  members  of 
the  communi^.  State  aid  in  the  form  of  fifty  per  cent. 
cash  grants  for  buildings,  a  cash  allowance  for  the  ^eatment 
of  free  patients,  together  with  certain  allowances  toward 
maintenance,  were  to  be  furnished  to  all  communities  fulfill- 
ing the  requirements  of  the  State  Department  of  Health.* 

THE  E£D  CROSS  PBOOBAH 

The  plan  for  tiie  extension  of  the  health  center  movement 
by  the  American  Red  Cross  may  be  best  described  by  the  oflS- 
cial  statement  distributed  from  National  Headquarters.** 
After  discussing  the  program  for  the  extension  of  public 
health  nursing  the  plan  for  health  centers  is  outlined  as 
follows : 

**The  time  has  come  for  the  announcement  of  the  second 
definite  step  in  the  Bed  Cross  health  program.  This  is  to  be 
the  mobilization  of  Bed  Cross  interest  and  influence  for  the 
establishment  of  health  centers  in  every  community  where 
conditions  make  this  desirable  and  possible.  These  modem 
community  stations  of  health  and  social  service  not  only 
promise  greater  eflSciency  in  the  public  and  volunteer  activi- 
ties in  this  field  but  offer  a  particular  opportunity  for  effec- 
tive Bed  Cross  participation.  In  many  communities,  partic- 
ularly those  without  a  health  organization  and  where  the 
Red  Cross  is  now  the  only  organized  social  agency,  the  health 
center  may  conceivably  begin  and  continue  as  a  purely  Red 
Cross  operation.  In  larger  cities,  with  their  well-established 
volunteer  associations  and  committees  and  their  more  highly 

•For  farther  deUils  of  tho  New  York  bill  see  State  CharltiM  Aid 
Association  News.  April,  1920.  This  bill  was  introduced,  bnt  not  acted 
upon,  dnring  the  1920  session. 

••  American  Ked  Cross  Circnlar  1000,  Sept.  29.  1919. 


HEALTH  CBNTEBS  107 

organized  official  pnblic  health  serrices,  the  health  center 
vaaj  mean  the  practical  physical  means  to  bring  about  better 
co-ordination  of  these  activities.  In  this  case  the  Bed  Cross 
may  initiate  the  movement  or  merely  participate  as  one 
among  other  agencies,  public  and  private.  Indeed  the  health 
center  idea  is  in  itself  capable  of  elastic  definition  to  meet  the 
drcnmstances  and  capacities  of  the  smiallest  as  well  as  the 
largest  Chapters.  A  handbook  will  be  issued  later  from 
National  Headquarters  covering  the  subject  in  fuller  detail; 
the  present  statement  is  intended  to  describe  briefly  the  nature 
and  purpose  of  health  centers  and  to  suggest  in  a  preliminary 
way  how  the  Bed  Cross  may  best  promote  their  establish- 
ment" 


C 


CHAPTER  Xn 

THE  SOOAL  UNIT  EXPERIMBNT 

Those  who  accept  the  idea  that  there  is  a  community  health 
problem  and  believe  that  it  is  to  a  large  extent  capable  of 
solution  wiU  find  interesting  and  instructive  reading  in  the 
reports  of  the  Social  Unit  experiment  at  Cincinnati,  Ohio. 

The  Social  Unit  Organization  has  been  described  briefly 
as  a  "nation-wide  organization  of  people  who  have  come  to- 
gether for  the  purpose  of  finding  some  way  to  increase  health, 
happiness  and  the  other  good  things  of  the  earth,  and  of  help- 
ing to  do  away  with  poverty,  misery,  disease  and  preventable 
death." 

The  National  Social  Unit  Organization  was  formed  in 
April,  1916,  with  headquarters  in  New  York  City.  The  pur- 
pose of  the  organization  is  stated  to  be  "to  promote  the  type 
of  democratic  community  organization  through  which  the 
citizenship  as  a  whole  can  participate  directly  in  the  control 
of  community  affairs,  while  at  Hie  same  time  making  con* 
stant  use  of  the  highest  technical  skill  available.'' 

After  some  deliberation,  the  Mohawk-Brighton  district  of 
Cincinnati  was  chosen  for  the  purpose  of  carrying  out  a 
Social  Unit  community  experiment  on  a  large  scale  and  a  sum 
of  money  was  appropriated  by  the  national  organization  for 
this  purpose. 

THE   SOOIAL   TJVTT   PLAK 

The  Social  Unit  plan  aims  to  combine  the  citizens  of  a 
community  into  groups,  the  members  of  which  will  develop 
the  activities  of  their  own  particular  group  for  the  benefit  of 
the  community  organization  as  a  whole.  Thus  the  physicians 
and  nurses  of  the  district  work  for  public  health;   the 

108 


THE  SOCIAL  UNIT  EXPERIMENT  109 

employers  and  trade  unionists  are  industrial  experts;  social 
workers  form  a  committee  on  public  welfare;  teachers  repre- 
sent the  Board  of  Education,  etc. 

Decision  as  to  various  health  measures  is  left  largely  to 
representatives  of  the  people  living  in  or  employed  in  the  dis- 
trict, but  the  execution  of  the  suggested  solutions  of  the 
health  problems  is  referred  to  the  Physicians  Council,  the 
Nurses  Council,  and  the  Social  Workers  Council. 

In  an  evaluation  of  the  Mohawk-Brighton  experiment  made 
by  Dr.  Haven  Emerson,  former  Commissioner  of  Health  for 
New  York  City,  the  following  statement  is  made:  'Inquiry 
develops  the  practical  unanimity  of  opinion  of  physicians  in 
the  district  that  the  medical  needs  of  the  district  have  been 
better  met  than  before,  that  medical  practice  had  benefited — 
these  are  questions  that  I  asked  specifically  of  the  doctors 
who  were  in  service  in  the  district  and  tiiose  outside  the 
working  group  who  had  taken  part  at  one  time  or  another  in 
the  actions  of  the  Medical  Council — that  the  medical  needs 
of  the  district  had  been  better  met  than  before,  that  medical 
practice  had  benefited  and  that  if  all  taint  of  donation  of  serv- 
ices were  removed  by  the  assumption  of  costs  by  those  who 
were  served,  there  would  be  no  further  reservation  in  the 
willingness  to  praise  and  approve  the  organization  and  its 
results." 

While  the  population  is  too  small  and  the  duration  ox  the 
experiment  too  short  to  permit  statistical  conclusion  based 
on  morbidity  records,  certain  very  valuable  results  have  been 
obtained,  according  to  Dr.  Emerson's  report,  and  these  results 
stand  as  tangible  evidence  of  improvement  in  health  condi- 
tions of  the  unit  area. 

In  the  first  place  a  very  high  percentage  of  expectant 
mothers  were  reached  and  pre-natal  advice  and  treatment 
given  when  necessary.  In  addition  early  and  continuous 
supervision  of  all  babies  born  in  the  district  was  secured  and 
adequate  care  given  the  mothers  during  the  period  immedi- 
ately following  confinement. 

C^dren  of  pre-school  age  were  examined  and  many  physi- 


^ 


110      THE  COMMUNITY  HEALTH  PEOBLEM 

cal  defects  discovered  and  corrected  before  the  child  entered 
schooL  It  has  been  said  that  all  children  are  entiUed  to  edu- 
cation. It  might  be  added  that  all  children  are  entitled  to 
begin  education  with  the  minimnTn  degree  of  physical  handi- 
cap. In  the  Mohawk-Brighton  District  many  of  the  physical 
defects  were  discovered  in  early  life  and  corrected  by  appro- 
priate treatment  either  by  private  or  public  medical  agencies. 

800IAL    UinT    NUBSINa 

Nursing  in  the  district  was  largely  carried  out  by  the  com- 
munity organization  along  lines  similar  to  the  district  nurs- 
ing plan.  When  the  patient  was  able  to  pay  from  his  own 
resources  private  nurses  were  employed.  In  most  cases,  how- 
ever, visiting  nurses  were  supplied  without  a  fee.  The  nurs- 
ing service  is  divided  into  maternity,  infant,  pre-natal,  pre- 
school, tuberculosis,  and  general  bedside  services.  Much  of 
the  work  done  by  the  nursing  staff,  as  might  be  expected, 
was  educational  in  character.  The  aim  was  education  in  per- 
sonal hygiene  through  skilled  nursing  care  for  the  ill  and  in- 
structive service  for  others.  During  the  first  year  of  the 
experiment  Social  Unit  nurses  reached  and  kept  under  ob- 
servation for  varying  periods  65  per  cent,  of  all  children  under 
two  years  of  age  in  the  district,  and  it  is  claimed  that  100  per 
cent,  of  all  children  having  serious  physical  defects  received 
nursing  supervision. 

During  the  influenza  epidemic  of  1918  more  than  3000 
visits  were  made  by  the  nursing  service  within  the  district, 
and  more  than  350  outside  of  the  district  limits. 

Miss  Zoe  La  Forge  of  the  Federal  Children's  Bureau,  in  a 
report  on  the  nuraing  situation,  says,*  'The  number  of  per- 
sons who  have  been  reached  compared  with  the  number  who 
might  have  been  reached  shows  a  completeness  which  is  ex- 
traordinary in  public  health  nursing  organizations.    This  fact 

•La  Forff*.  Miss  Zo«:  Tb«  Social  Unit  and  Public  Health  Nnrslns. 
Report  of  Social  Unit  Conference.  National  Social  Unit  Organ.  Mew 
York,  1S19. 


■"^ 


THE  SOCIAL  UNIT  EXPEBIMENT  111 

is  even  more  impressiye  in  view  of  the  short  time  in  which 
these  results  were  obtained." 

TUBEBCULOSIS    ACTIVITIES 

"Work  in  the  field  of  tuberculosis  was  begun  in  May,  1918, 
in  co-operation  with  the  Anti-Tuberculosis  League  of  Cincin- 
nati. Nurses  were  assigned  to  the  district  and  it  is  probable 
that  most  cases  of  active  pulmonary  tuberculosis  were  discov- 
ered and  brought  under  treatment.  Of  179  new  cases  reported 
during  the  year  103  were  located  by  those  working  within  the 
unit  itself.  A  large  part  of  this  increase  was  without  doubt 
due  to  the  general  good  will  of  the  people  toward  the  unit- 
workers  combined  with  the  ability  of  the  block-workers  to 
win  the  confidence  of  their  families.  Many  cases  of  pulmo- 
nary tuberculosis  were  discovered  during  the  early  stage  and 
as  a  result  were  suitable  for  sanitarium  treatment.  Arrested 
cases  remained  at  home  under  expert  medical  and  nursing 
supervision. 

HSDICAL  CARE 

The  medical  services  of  the  unit  are  directed  by  the  Medi- 
cal Council  which  is  composed  of  32  of  the  38  physicians 
living  or  practising  within  the  district.  Sixteen  of  these  phy- 
sicians are  employed  on  part  time  at  $3  per  hour  in  profes- 
sional work  at  the  center,  chiefly  examining  children  or 
adults.  Treatment  at  the  center  is  given  by  these  physicians 
only  in  emergencies.  When  the  need  of  medical  treatment 
arises  patients  are  referred  to  their  own  physicians,  or  to  the 
free  dispensary  or  hospital.  When  needy  patients  require 
treatment  at  home  the  service  is  rendered  by  a  physician  from 
the  City  Health  Department.  Medical  service  in  the  homes 
is  not  considered  to  be  within  the  province  of  the  health  ac- 
tivities so  far  called  for  by  the  Citizens'  Council.  The  family 
physician  is  informed  of  the  need  for  treatment  and  the 
patient  notified  that  medical  care  is  required.  The  free  choice 
of  physicians  is  encouraged. 


112      THE  COMMUNITY  HEALTH  PBOBLEM 

BSNSVlXtt  OF  BEALTH  8SSVI0S 

The  faienefit  derived  from  periodical'  examinationa  and 
medical  anpervision  cannot  be  overestimated.  As  a  result  of 
this  service  combined  with  nursing  service  and  the  health 
educational  activities  of  the  center,  physical  defects  receive 
early  attention  by  both  patients  and  physicians.  The  relation 
between  patient  and  physician  is  not  disturbed  but  is  as  a 
rule  greatly  improved.  The  physician  is  stimulated  to  do  his 
best  work  and  the  patient  is  taught  just  what  he  may  ex* 
pect  from  a  given  remedial  measure  so  that  there  is  consid- 
erably less  criticism  of  the  methods  employed^  when  illness 
results  unfavorably,  than  is  the  case  in  ordinary  private  prac- 
tice. Exploitation  of  the  sick  by  unscrupulous  physicians  is 
reduced  to  a  minimum. 

As  a  whole  the  healtii  service  may  be  said  to  be  divided  into 
three  sections. 

(a)  Medical  Service  furnished  in  part  by  private  physi- 
cians with  the  co-operation  of  private  and  public  hospitals  and 
the  Department  of  Health.  This  part  of  the  service  is  no  dif- 
ferent from  that  of  any  other  section  of  the  city.  The  only 
new  element  in  the  unit  experiment  is  medical  supervision 
by  a  medical  council. 

(b)  Nursing  service  furnished  on  the  district  nursing  plan 
free  to  all  who  will  accept  it. 

(c)  Public  health  service  furnished  in  part  by  the  citizens 
themselves,  in  part  by  the  public  health  authorities,  in  part 
by  welfare  workers  of  the  Social  Unit,  and  in  part  by  certain 
other  outside  organizations. 

The  health  service  indicated  certain  gross  sanitary  defects 
which  were  corrected  through  co-operative  action  of  citizens, 
landlords  and  tenants.  The  education  of  the  mass  of  the  pop- 
ulation in  health  matters,  having  led  apparently  to  a  desire 
for  general  sanitary  cleanliness  combined  with  an  under- 
standing of  the  relation  of  health  to  their  own  and  their  chil- 
dren's welfare,  was  an  important  factor  in  securing  prompt 
action  leading  to  the  correction  of  sanitary  defects. 


THE  SOCIAL  UNIT  EXPERIMENT  113 

jiniong  the  citizens  themselves  the  results  have  been  ex- 
cellent. The  public  has  been  educated  in  the  possibilities  of 
increased  happiness  through  increased  health  and  especial 
emphasis  has  been  placed  upon  the  £rm  establishment  of  the 
belief  that  reasonable  efforts  spent  for  the  improvement  of 
health  are  not  wasted  but  bring  results  out  of  all  proportion 
to  the  expense  incurred. 

CEinCISM   OP    THB   SOCIAL    UNIT   PLAN 

The  Social  Unit  experiment  has  been  severely  criticised. 
"While  its  critics  admit  that  it  has  done  much  good  they  con- 
tend that  this  has  only  been  accomplished  because  the  unit 
has  been  experimental  and  that  all  parties,  citizens,  execu- 
tives and  workers  are  working  largely  on  the  enthusiasm  of 
new  ideas  and  novel  conceptions  of  public  welfare.  They 
believe  that  over  a  large  territory,  lacking  this  enthusiasm 
and  the  inspiration  of  a  unique  experiment,  the  workers 
would  lose  interest  and  the  results  would  consequently  be 
negligible.  It  is  claimed  by  some  that  the  Social  Unit  is  rev- 
olutionary and  represents  a  dangerous  competitor  to  existing 
political  institutions. 

Others,  notably  the  inhabitants  of  the  Mohawk-Brighton 
District,  favor  the  experiment.  Welfare  workers  as  a  rule 
favor  the  project  and  believe  that  actnal  results  obtained  have 
been  amazing. 

Besides  being  a  health  experiment  the  Social  Unit  is  dis- 
tinctly a  social  experiment.  Social  and  health  activities  are 
based  largely  upon  decisions  of  the  citizens  themselves  acting 
through  their  councils  and  executives.  There  is  no  disputing 
the  fact  that  some  remarkable  resiilts  have  been  obtained. 
Whether  another  group  of  citizens  would  do  as  well  is  pos- 
sibly debatable. 

At  all  events  a  reasonably  satisfactory  partial  solution  of 
the  community  health  problem  has  been  obtained.  Whether 
this  is  the  result  of  the  Social  Unit  plan  of  community  gov- 
ernment or  whether  it  is  largdy  due  to  the  intelligence  and 


114      THE  COMMUNITY  HEALTH  PROBLEM 

energy  of  the  ezecntiTes  sent  to  Cinciimati  by  the  National 
Social  Unit  Organization  is  at  present  undetermined.  Every 
commnnity  is  entitled  to  healtii  conditions  at  least  as  good 
as  those  in  the  Mohawk-Brighton  District.  Possibly  com- 
mnniiy  organization  is  the  only  way  to  obtain  it. 

The  residents  of  this  district  in  the  face  of  a  newspaper 
criticism  by  the  Mayor  of  Cincinnati,  recorded  their  desire 
that  the  Social  Unit  shonld  continue  its  woric  by  a  vote  of 
4434  to  120. 


CHAPTER  XIII 


TUBERCULOSIS 


Tuberculosis  has  been  called  the  burden  of  modem  civili- 
zatioiL  It  is  without  doubt  the  most  widespread  of  all  major 
illnesses.  Coming  as  it  does  during  an  early  period  in  life^ 
attacking  members  of  every  strata  of  society  and  causing  a 
tremendous  annual  loss  of  life,  it  presents  the  most  im- 
pori;ant  menace  to  community  health  which  modem  society 
must  face. 

Approximately  150  individuals  in  every  100,000  die  annu- 
ally from  pulmonary  tuberculosis.  In  some  of  the  larger 
cities  this  number  is  increased  to  200  or  even  higher.  "When 
we  consider  that  tuberculosis  is  a  disease  of  several  years* 
duration  and  that  many  persons  suffering  from  the  disease 
are,  except  during  the  later  stages,  usually  up  and  about  at- 
tending to  their  normal  occupations,  together  with  the  fact 
that  comparatively  few  cases  are  reported  to  the  public  health 
authorities  during  the  early  stage,  it  becomes  at  once  evident 
that  there  must  be  a  large  number  of  untreated  and  unsus- 
pected cases  in  every  community.  It  is  ordinarily  estimated 
that  there  are  at  least  nine  active  cases  for  every  death  from 
the  disease. 

DISTBIBUnON    OP    TUBERCLE    BACILLI 

The  distribution  of  the  tubercle  bacilli  is  almost  universal. 
Pathologists  teU  us  that  practically  100  per  cent  of  all  adults 
dying  from  accident  show  evidences  of  tuberculosis.  The 
signs  of  the  disease,  it  is  true,  are  in  most  cases  only  minor 
lesions  and  have  little  or  no  clinical  significance  except  for 
the  fact  that  they  point  to  the  wide  distribution  of  the  causa- 

115 


^ 


116      THE  COMMUNTTT  HEALTH  PBOBLBM 

tiTe  organism.  From  a  medical  standpoint  sncli  cases  are  not 
considered  clinically  as  tabercnlosis.  Only  when  the  disease 
becomes  progressive,  or  when  the  growth  of  the  organism 
tends  to  overcome  the  resistance  of  the  individual  do  we 
speak  of  the  condition  as  tuberculosis. 

We  know  the  cause  of  tuberculosis,  we  know  how  the  dis- 
ease is  spread,  and  we  know  that  it  can  frequently  be  arrested. 
We  have  therefore  a  condition  which  should  be  peculiarly 
susceptible  to  control,  and  to  a  d^ee  we  may  say  that  ef- 
forts  to  this  end  have  been  fairly  successfuL  In  the  registra- 
tion area  of  the  United  States  there  has  been  an  almost  con- 
stant decline  in  the  tuberculosis  mortality  rates  from  200.7 
per  100,000  in  1904  to  146.4  per  100,000  in  1917.  This  de- 
crease has  been  due  largely  to  existing  public  and  private 
agencies  for  the  control  of  tuberculosis  and  to  improvement 
in  the  social  and  medical  treatment  of  patients  sufEering 
from  the  disease. 

THB    CONTROL    OF   TUBEBOULOBIS 

In  attempting  to  control  tuberculosis  one  of  two  altema- 
tivM  may  be  adopted.  .We  may  discard  the  existing  agencies 
and  with  a  new  broom  make  a  clean  sweep  of  all  society,  at- 
tempting the  complete  removal  of  all  infectious  individuals 
from  their  surroundings  and  starting  anew  with  the  re- 
mainder to  create  a  new  civilization.  Such  a  plan  has  been 
proposed,  including  the  complete  isolation  of  the  tuberculous 
and  legal  restrictions  against  marriage,  but  fortunately  for 
the  peace  of  the  world  the  attempt  has  never  been  made  to 
put  this  proposed  plan  into  execution.  The  other  alternative 
is  to  continue  what  we  have  been  doing,  only  expanding 
OUT  energies  so  that  what  we  already  know  may  be  carried 
to  every  comer  of  the  country;  so  that  every  individual  will 
have  placed  before  him  the  best  that  our  present  knowledge 
has  to  offer,  while  at  the  same  time  we  make  every  effort  to 
improve  our  methods,  to  correct  our  mistakes  and  develop  a 


TUBERCULOSIS  117 

spirit  of  co-operation  between  the  scientist,  the  physician,  the 
patient,  the  legislator  and  the  man  on  the  street. 

Much  that  is  said  of  the  control  of  tuberculosis  may  be 
said  of  almost  any  health  problem  in  the  community.  The 
campaign  against  this  disease  in  the  past  has  been,  and  is 
apt  to  continue,  under  the  joint  control  of  the  state,  or 
municipal,  authorities  and  various  private  organizations. 
Each  has  its  own  part  to  play  and  none  could  function  ade- 
quately to  the  exclusion  of  the  others. 

Private  organizations  should  be  devoted  largely  to  re- 
search, experimentation,  education  and  observation.  They 
should  be  depended  upon  to  stimulate  interest,  to  point  out 
new  fields  and  to  indicate  methods  of  procedure.  Qovem- 
mental  activities  should  be  devoted  largely  to  the  execution 
of  plans  previously  initiated  by  private  organizations. 

The  following  is  the  general  plan  of  a  tuberculosis  pro- 
gram -which  has  been  outlined  by  Dr.  Donald  B.  Armstrong  :* 

1.  Organization:  Lay  and  professional  organizations,  in- 
terest>  co-ordination,  education,  public  service,  ideals. 

3.  Legislation:  Sanitary,  epidemological,  institutional 
provision  and  appropriations. 

3.  Sanitation:  Cleanliness,  respiratory  hygiene,  food  pro- 
tection, control  of  spitting,  etc 

4.  Disease  Detection:  Reporting  of  disease  by  physicians 
and  clinics,  the  establishment  of  new  clinic  facilities,  infant 
welfare  and  school  hygiene,  special  consultation  service,  etc. 

5.  Classification:  The  standardization  of  reports  and  clas- 
sifications. 

6.  Treatment:  (A)  Home  treatment  including  nursing, 
relief,  etc.;  (B)  Institutional  treatment,  including  sanitoria, 
day  camps,  etc. 

7.  Subsequent  observation:  Follow-up  work  with  economic 
adjustment  and  the  conservation  of  health. 

8.  Prevention:  By  sanitary  hygiene,  education,  by  the  pre- 

*Annstrong,  Donald  B. :  Journal  of  Outdoor  Life,  Jan.,  1920. 


r 


118      THE  COMMUNITY  HEALTH  PROBLEM 

y^tion  of  the  spread  of  infection,  and  by  general  efforts  to 
increase  resistance. 

9.  Beseaich  and  Demonstration:  The  development  of  a 
scientific  inqoiry  into  the  methods  of  prevention  and  core, 
and  into  social  questions  combined  with  the  demonstration 
of  methods. 

A  program  snch  as  the  above  can,  with  dight  modifica- 
tion, be  adapted  to  many  other  diseases.  In  a  commnnity 
where  health  work  is  being*  started  from  the  b^inning,  and 
especially  where  there  are  only  limited  funds  available,  it  ia 
sometimes  desirable  to  limit  the  work  temporarily  to  mens- 
nres  to  combat  tuberculosis.  This  disease  lends  itself  par- 
ticularly to  welfare  work  because:  (1)  The  disease  is  chronic; 
(2)  A  large  amount  of  preliminary  work  has  been  done  so 
liiat  there  need  be  little  lost  energy;  (3)  There  is  a  flourish- 
ing national  organization  willing  and  anxious  to  furnish 
assistance  and  guidance. 

In  carrying  out  a  tuberculosis  program  there  will  be  dis- 
covered a  tremendous  number  of  other  diseases  which,  because 
they  undermine  the  general  health,  predispose  to  tuber- 
culosis. By  concentrating  on  tuberculosis  in  the  begin- 
ning the  other  unfavorable  conditions  are  soon  brought  to 
lighi. 

In  the  treatment  of  the  tuberculosis  problem  there  arise 
many  closely  related  problems  of  sanitation  and  general 
health  which  in  many  cases  are  capable  of  easy  solution  but 
which  in  most  communities  are  being  handled  indifferently 
or  not  at  aiL 

THE  DI8C0VEBT  OP  EVERY  CASE 

The  most  important  phase  of  the  tuberculosis  problem  Has 
to  do  with  the  discovery  of  all  existing  cases,  that  is,  the 
bringing  of  all  tuberculous  individuals  and  all  suspects  under 
competent  medical  care. 

The  experience  of  Dr.  Donald  B.  Armstrong  in  Framing- 
ham,  Mass.,  a  city  of  about  17,000  inhabitants,  has  been 


TUBBBCTTLOSIS  119 

interesting  as  showing  how  many  cases  may  be  brought  to 
light  by  a  careful  medical  survey.  On  January  1,  1917,  there 
were,  according  to  the  official  records,  27  cases  under  obser- 
vation in  the  ciiy.  On  November  15,  1918,  as  a  result  of 
the  survey,  there  were  under  observation  181  cases  and  69 
suspects.  During  this  period  there  were  29  deaths  and  33 
patients  moved  to  other  localities.  The  source  of  the  242 
positive  cases  was  as  follows: 

TABLE  OP  ORIGIN  OP  TDBEB0UL0SI8  OASES* 

Previously  known  27 

Medical  examination  drives  96 

Draft  13 

Consultation  53 

Private  physicians'  reports  40 

School  medical  work  11 

Factory  medical  work  2 

Total  242 

From  the  above  table  it  is  evident  that  a  careful  medical 
survey  may  demonstrate,  at  a  very  conservative  estimate,  at 
least  one  undiscovered  case  of  tuberculosis  for  every  reported 
case  in  a  typical  American  community.  It  is  probable  that 
this  estimate  errs  on  the  side  of  conservatism  and  that  in 
fact,  there  are  nearer  two  undiscovered  cases  for  every 
reported  case. 

MEDICAL  CARE  FOB  THE  TUBERCULOUS 

The  next  major  problem  has  to  do  with  the  securing  of 
treatment  for  every  active  case  of  pulmonary  tuberculosis. 
Let  us  suppose  that  every  case  has  been  discovered,  how  then 
are  we  going  to  secure  the  maximum  benefit  of  treatment  for 
each  and  every  patient?  This  becomes  at  once  an  economic, 

•Armstroni?.  Donald  B.:    Tubercalosls  Flndisge,  Fr«mlBgliaxn  Mono* 
^aph  No.  6.  March,  1919. 


120      THE  COMMUNITY  HEALTH  PEOBLEM 

AS  well  as  a  social  and  medical  problem.  A  certain  percent- 
age of  the  patients  will  be  able  to  continne  tlieir  old  occupa- 
tions and  will  require  a  minimnm  of  medical  attention.  A 
somewhat  larger  proportion  will  not  improve  in  their  present 
occupations,  but  will  improve  if  they  are  placed  in  more 
favorable  snrronndings.  Many  will  be  unable  to  do  any  work 
and  must  be  either  treated  at  home  or  sent  to  a  sanitorium. 
The  economic  problem  becomes  most  acute  when  the  bread 
winner  is  attached  and  unable  to  support  his  family.  It  is 
useless  to  tell  such  a  man  that  he  must  ''get  away  and  take  a 
long  rest."  Unless  provision  is  made  for  his  family  he  will 
be  unable  to  stop  work  until  the  disease  has  progressed  so  far 
as  to  render  him  physically  unfit.  At  this  stage  the  disease  is, 
of  course,  unfavorable  for  treatment. 

AFIEB-CASB  OF  TH£  TUBEBGULOUS 

The  third  phase  of  the  problem  has  to  do  with  the  care  of 
the  arrested  case.  It  is  customary  in  such  cases  to  tell  the 
patient  that  he  may  now  return  home  and  'to  secure  some 
.form  of  light  out-door  work.''  For  the  average  man  such 
advice  is  worse  than  useless.  Those  who  have  tried  say  that 
light  out-door  work  practically  is  non-existent.  The  chief 
out-door  occupation  is  fanning  which  is  far  from  a  light 
occupation.  If  an  arrested  case  is  allowed  to  go  back  to  hard 
manual  labor  immediately  upon  discharge  from  tiie  sani- 
torium  a  relapse  of  the  disease  is  almost  certain  to  occur  and 
the  results  of  treatment  are  completely  counteracted,  thereby 
causing  economic  loss  both  to  the  man  and  the  community. 

The  problem  has  been  solved  in  a  large  way  only  in  a  few 
communities.  Certain  industrial  organizations,  notably  the 
Ford  Company,  have  established  special  work  rooms  for 
arrested  cases  of  tuberculosis  where  they  are  given  light  woik 
in  hygienic  surroundings,  under  the  care  of  a  physician.  The 
results  of  this  plan  have  been  most  successful  and  the  future 
of  what  might  be  called  "occupational  therapy*'  for  incipient 
and  inactive  tuberculosis  IB  carefully  selected  cases  is  most 
promising. 


TUBERCULOSIS  121 

The  U.  S.  Public  Health  Service  has  outlined  a  program* 
for  1920  which  includes:  (a)  Stringent  provisions  for  the 
proper  reporting  of  cases  of  tuberculosis;  (b)  Adequate 
instruction  of  families  and  patients,  especially  in  families 
where  there  is  an  advanced  case;  (c)  Hospitalization  of 
cases,  wherever  practicable,  either  through  city  institutions, 
or  by  arrangements  with  state  and  district  tuberculosis  hos- 
pitals; (d)  Co-operation  with  national  societies  and  agencies 
having  for  their  object  the  prevention  of  tuberculosis  or  the 
improvement  of  economic  conditions;  (e)  Improvement  of 
industrial  conditions  predisposing  to  tuberculosis,  such  as 
dusty  occupations,  defective  ventilation,  etc. 

For  the  average  community  where  it  is  desired  to  make  a 
beginning  in  constructive  health  work  the  campaign  may 
often  be  centered  about  the  tuberculosis  problem.  So  many 
welfare  measures,  such  as  better  housing,  child  welfare,  nutri- 
tion, etc.,  are  so  intimately  connected  with  the  control  of 
tuberculosis  that  activities  undertaken  with  the  aim  to  pre- 
vent the  spread  of  this  disease  serve  to  direct  attention  to 
community  sickness,  and  at  the  same  time,  tend  to  improve 
general  community  health. 

•Annnal  B«port,  1019,  V.  8.  Public  Sultb  Bwrie*,  WuMagton,  D.  C 


^ 


CHAPTER  XIV 

SOaAL  HYGIENE  IN  ITS  RELATION  TO  COMNfUNTIT 
HEALTH 

In  eyery  commnnity  there  is  what  has  come  to  be  known 
as  a  "social  hygiene"  problem,  meaning  thereby  a  problem 
which  has  to  do,  in  part,  with  the  prevention  of  venereal 
diseases.  In  many  of  the  smaller  communities  the  presence 
of  sex  diseases  may  be  denied  but  if  a  careful  search  be  made, 
in  every  group  containing  several  thousand  persons,  evidence 
of  sex  disease,  either  past  or  present,  will  almost  certainly 
be  found  in  a  fairly  definite  proportion  of  the  total. 

No  plan  of  health  improvement  can  be  considered  com- 
plete imless  the  question  of  social  hygiene  receives  due  con- 
sideration. The  prevention  of  sexual  diseases  has  been  fre^ 
qnently  attempted  and  for  the  most  part  attempts  have  met 
with  little  or  no  success.  The  problem  is  so  complicated  by 
personal  habits,  social  institutions,  and  by  community  and 
national  customs  that  the  medical  aspects  of  the  question 
become  obscured  by  the  sociological  and  economic  problems 
which  present  tiiemselves. 

MEDICAL  CONTBOL   POSSIBLE 

As  far  as  the  science  of  medicine  is  concerned  there  is  no 

mystery  in  any  of  the  various  sex  diseases.   They  are  all  of 

them  transmitted  only  by  direct  contact,  they  are  all  more 

or  less  easily  curable  and  their  transmission  from  one  person 

to  another  is  comparatively  diflBcult.    They  are  not  spread 

by  air  currents  as  are  measles  and  smallpox,*  they  are  not 

disseminated  through  infected  water  or  food  as  are  typhoid 

*Tli*  spread  of  xneftsIeB  and  Gmallpox  by  air  cnrrents  is  not  definitely 
proven.  Some  writers  deny  that  this  can  occur.  However,  Infection 
does  ocenr  from  very  slight  contact  In  both  of  these  diseases,  possibly 
carried.  In  some  cases  at  least,  in  mlnate  droplets  of  molstorv 
•spoiled  In  congblng  or  sneeslng. 

122 


HYGIENE  IN  ITS  RELATION  TO  HEALTH    123 

and  dysentery,  and  they  are  not  carried  by  insects  as  are 
malaria  and  typhns.  Moreover  the  micro-organisms  are  not 
'scattered  broadcast  as  are  the  germs  of  pns-f orming  infections 
bnt^  in  practically  every  case,  the  disease  must  be  spread 
directly  from  person  to  person  and  the  contact  must  be 
intimate  and  prolonged. 

Even  when  such  is  the  case  an  abrasion  or  wound  of  the 
surface  is  in  certain  cases  necessary  for  the  introduction  of 
the  infective  material. 

Here  then  from  a  medical  standpoint  we  have  disease  which 
should  be  very  easily  controlled.  All  that  is  necessary  is  to 
quarantine  every  case  during  the  infectious  stage,  and  the 
disease  will  disappear.  But  this  is  more  easily  said  than  done. 
In  the  first  place  venereal  diseases  exist  to  such  an  extent 
that  quarantine  is  impracticable.  In  the  next  place  the 
social  disgrace  of  sexual  infection  is  so  great  that  many  per- 
sons will  do  their  utmost  to  prevent  the  discovery  of  the 
fact  that  they  are  suffering  from  such  disease.  And  last,  and 
in  my  opinion  most  important  of  all,  is  the  fact  that  these 
diseases  are  often  so  mild  as  to  escape  the  knowledge  of  the 
patient  himself  or  at  least  so  mild  as  to  permit  him  to  delude 
himself  into  believing  that  his  disease  is  not  serious.  If 
venereal  diseases  occurred  in  acute  attacks,  as  severe  as  typhoid 
fever  or  smallpox,  detection  would  be  easy,  all  cases  would 
come  under  treatment,  the  spread  of  infection  would  auto- 
matically stop,  and  the  venereal  disease  problem  would  soon 
become  comparatively  insignificant 

HILITABY    COirrBOL   OF   SEX   DISEASES 

In  a  military  community  where  all  the  members  of  the 
community  are  under  strict  control  sexual  diseases  may  be 
reduced  to  a  TnirtinmTn  This  has  been  frequently  proven  in 
the  United  States,  and  was  demonstrated  on  a  tremendous 
scale  in  the  American  Expeditionary  Forces  where  the 
Tenereal  admission  rate  was  extremely  low.    However  the 


i^ 


•124      THE  COMMUNITY  HEALTH  PBOBLEM 

methocb  which  were  used  in  the  Army  are  for  many  leasoxu 
considered  impracticable  in  civil  life. 

Nevertheless  the  study  of  social  hygiene  received  a  great 
stinmlns  during  the  war  period.  It  was  realized  that  here 
was  a  live  problem  which  must  be  recognized  and  faced  be- 
fore  conditions  could  be  bettered.  In  the  past  there  has 
always  been  a  strong  tendency  to  deny  what  was  considered 
objectionable  and,  in  America  especially,  many  persona  con- 
sidered that  it  was  immoral  even  to  admit  that  such  dis- 
eases existed. 

For  some  years  the  American  Social  Hygiene  Association, 
the  U.  S.  Public  Health  Service,  the  American  Bed  Cross, 
and  various  city  and  state  health  departments  have  been 
attempting  to  stimidate  interest  in  the  problem  of  social 
hygiene  in  order  to  diminifth  all  forms  of  veneral  disease, 
witibout  however  meeting  with  any  great  amount  of  co-opera- 
tion from  either  the  public  or  the  medical  profession. 

PUBLIO    HEALTH   8EBVICB    OAMPAIQK 

During  the  war  however  the  United  States  Public  Health 
Service  outlined  a  nationwide  campaign  against  venereal 
diseases  to  be  carried  out  in  co-operation  with  state  and  local 
health  authorities  and  various  welfare  organizations.  In  July, 
1918,  the  Chamberlain-Kahn  bill  was  passed  by  Congress  es- 
tablishing a  Division  of  Venereal  Diseases  in  the  Public 
Health  Service  and  an  Interdepartmental  Social  Hygiene 
Board.  The  Surgeon-General  of  the  Public  Health  Service 
characterized  the  bill  as  the  most  important  public  health 
legislation  ever  enacted  by  law. 

The  duties  of  the  Division  of  Venereal  Diseases  were  out- 
lined  as  follows : 

1.  'To  study  and  investigate  the  cause,  treatment  and  pre- 
Tention  of  venereal  diseases;" 

2.  ''To  co-operate  with  State  Boards  of  Health  for  the  pre- 
vention and  control  of  such  diseases  within  the  states;  and" 

•Fierce.  C.  C. :  Tb*  Public  Health  Campalga  afalait  YtttrMl  DImmh^ 

Social  Hygiene,  October,  1918. 


*> 


HYGIENE  IN  ITS  EELATION  TO  HEALTH    125 

3.  To  control  and  prevent  the  spread  of  these  diseases  in 
interstate  traflBc.** 

In  addition  to  inteistate  quarantine  regulations  which  for- 
bid interstate  travel  of  persons  infected  with  venereal  dis- 
ease except  under  a  permit  of  the  local  health  officer,  a  bill 
was  introduced  to  make  certain  United  States  appropriations 
available  to  local  health  authorities  who  would  co-operate 
with  the  Public  Health  Service  for  the  prevention  of  vene- 
real disease.  Definite  TnininniTn  requirements  were  estab- 
lished which  must  be  met  before  such  appropriations  are 
available  for  local  or  state  health  activities.  The  TniniTnum 
requirements  are,  briefly,  as  follows : 

(a)  ''Venereal  diseases  must  be  reported  to  the  local  health 
authorities  in  accordance  with  state  regulations  approved  by 
the  United  States  Public  Health  Service.*' 

(b)  'Tenalty  to  be  imposed  upon  physicians  or  others 
required  to  report  venereal  infections  for  failure  to  do  so." 

(c)  "Cases  to  be  investigated,  so  far  as  practicable  to  dis- 
cover and  control  sources  of  infection." 

(d)  'The  spread  of  venereal  disease  should  be  declared 
unlawful." 

(e)  *Trovision  to  be  made  for  the  control  of  infected  per- 
sons who  do  not  co-operate  in  protecting  others  from  infec- 
tion." 

(f )  ''The  travel  of  venereally  infected  persons  within  the 
slate  to  be  controlled  through  state  boards  of  health  by  defi- 
nite regulations  that  mR  conform  in  general  with  tibe  inter- 
state regulations  to  be  established." 

(g)  "Patients  to  be  given  a  printed  circular  of  instructions 
informing  them  of  the  necessity  of  measures  to  prevent  the 
spread  of  infection,  and  the  importance  of  continuing  treat- 
ment." 

nxATiaaTT  should  bs  haos  atiilablx 

Prom  a  medical  viewpoint  eveiy  case  should  have  the  oppop^ 
tunity  of  securing  expert  treatinent  at  a  moderate  price. 


f! 


126      THE  COMMUNITY  HEALTH  PBOBLEM 

There  hu  been  a  tremendons  amount  of  exploitatioii  of 
patients  by  the  so-called  ''adTertising  specialists.''  It  is  even 
aigned  by  certain  oonservatiTe  physicians  that,  becanse  men 
develop  these  diseases  mainly  as  a  result  of  their  own  mis- 
condncty  they  should  be, made  to  pay  high  fees.  Many  pri- 
vate practitioners  take  little  interest  in  such  cases  and  prefer  » 
to  send  them  elsewhere  for  treatment.  This  together  with  the 
stigma  of  disgrace  which  is  attached  to  venereal  infection 
has  driven  many  men  to  the  advertising  specialist  for  treat- 
ment  or  has  resulted  in  self  medication.  Drug  manufacturers 
have  become  enormously  rich  from  dividends  derived  from 
the  sale  of  patent  medicines  for  the  cure  of  sex  diseases. 

It  is  most  important  that  every  community  recognize  that 
it  is  better  to  treat  these  diseases  at  the  expense  of  the  public 
than  to  allow  them  to  remain  untreated.  This  is  best  accom- 
plished by  the  establishment  of  a  dispensary  where  treatment 
can  be  had  for  the  asking  for  a  nominal  charge,  or  for  no  fee 
at  all  if  requested. 

In  general  the  campaign  should  be  laid  out  along  the  fol- 
lowing lines:  (a)  Education;  (b)  Treatment;  (c)  Legisla- 
tion; (d)  Recreation.  If  the  need  is  recognized  and  advan- 
tage is  taken  of  efforts  of  the  Public  Health  Service,  and  the 
various  local  and  state  health  authorities,  a  great  deal  may  be 
accomplished.  If  on  the  other  hand,  the  presence  of  a 
venereal  problem  is  denied  or  if  the  subject  is  dielved  because 
it  is  considered  indecent  and  immoral,  and  consequently  unfit 
for  discussion,  the  contagion  will  continue  and  the  coming 
generation  will  pay  the  price.  Still-births,  blindness,  paraly- 
sis, insanity,  and  many  chronic  partially-incapacitating 
diseases  frequently  follow  untreated  veneral  diseases.  Such 
bad  results  can  nearly  always  be  prevented  by  early  and  ef- 
ficient treatment.  Social  ostracism  as  a  thereapeutic  measure 
in  the  cure  of  venereal  disease  has  always  been,  and  always  will 
be,  a  failure.  It  is  in  line  with  modem  social  progress  to 
divorce  entirely  the  moral  from  the  medical  in  the  treatment 
of  disease.  It  is  impossible  to  deny  the  presence  of  venereal 
diseases  in  the  community;  it  is  criminal  to  ignore  Ihem. 


HYGIENE  IN  ITS  KELATION  TO  HEALTH    127 

Yarions  other  measures  for  the  control  of  venereal  diseases, 
such  as  the  elimination  of  the  so-called  "red  light  district/' 
the  segregation  of  prostitutes,  compulsory  quarantine  during 
the  infectious  stage,  and  other  similar  measures  which  have 
been  advocated  from  time  to  time  are  not  considered  within 
the  scope  of  this  chapter.  For  a  further  discussion  of  this 
question,  especially  in  its  social  and  economic  aspects,  the 
reader  is  referred  to  the  various  publications  of  the  Ameri- 
can Social  Hygiene  Association. 


t 


CHAPTBB  XV. 
RBHABIUTATION  OF  THE  DISABLED 

It  is  self  evident  that  the  soldier  who  has  done  his  dnfy  in 
military  seryice  and  returned  to  his  home  wounded  and  per- 
manently disabled  must  not  be  allowed  to  resign  himself  to 
a  life  of  idleness,  depending  solely  upon  his  government  pen- 
sion for  support.  Such  a  procedure  is  demoralizing  both  to 
the  dischaiged  soldier  and  to  the  community. 

Neither  should  he  be  encouraged  to  depend  upon  irregular 
work  of  an  unskilled  nature  if  he  has  within  him  capabili- 
ties of  something  better. 

Following  the  activities  of  the  war  and  the  long  period  of 
idleness  in  the  Army  hospitals  there  is  often  a  period  oi, 
depression.  The  wounded  soldier  is  apt  to  decide  that  he  is  a 
'Qias  been,"  that  he  is  seriously  handicapped^  and  cannot  hope 
to  compete  with  the  physically  fit  and  that  he  will  be  unable 
to  earn  a  satisfactory  living.  He  feels  that  there  is  nothing 
left  to  do  except  resign  himself  to  the  inevitable.  This  men- 
tal condition  is,  in  some  cases,  a  state  of  depression,  so  marked 
that  it  causes  the  man  to  avoid  his  friends  and  acquaintances, 
to  become  morose  and  to  be  considered  moody  and  unfriendly 
by  those  with  whom  he  is  brought  in  contact.  Place  this 
same  man  in  a  gainful  occupation,  make  it  possible  for  him 
to  support  a  family,  let  him  feel  that  he  has  a  place  in  the 
community,  and  immediately  his  whole  character  changes,  he 
is  able  to  look  his  fellow  in  the  eye  without  a  feeling  of 
humiliation  and,  as  a  consequence,  when  at  work  he  often 
makes  faster  progress  and  does  better  work  than  his  uninjured 
co-workers. 

Douglas  C.  McMurtrie  has  pointed  out  that,  throughout 
history,  the  disabled  and  deformed  man  has  heea  a  castaway 

128 


EEHABIUTATION  OF  THE  DISABLED       129 

of  society,  that  the  tribes  of  ancient  India  tnmed  ont  their 
deformed  members  to  wander  in  the  wilderness,  and  that  the 
ancient  Hebrews  banished  cripples  and  forced  them  to  beg 
at  the  roadside.  Eidicule  and  suspicion  were  frequently 
directed  against  the  deformed,  and  at  one  time  it  was  widely 
believed  that  some  evil  power  rested  in  the  deformed  or  crip- 
pled body.*  During  the  last  century  however  there  has  been 
a  rapid  change  for  the  better,  beginning  with  pension  laws 
and  toward  the  end  expanding,  with  the  broadening  concep- 
tion of  the  responsibility  of  the  community,  through  the  enact- 
ment of  compensation  laws  and  laws  for  vocational  training. 
It  is  to  be  hoped  that  the  problem  of  the  disabled  soldier 
is  not  to  be  a  permanent  one  and  that  the  splendid  efforts 
which  have  been  made  by  the  Federal  Grovemment  will  not 
soon  again  be  required  for  those  injured  in  war.  The  lesson 
once  learned,  however,  must  not  be  forgotten  and  the  obvious 
advantages  of  vocational  training  for  the  war  cripple  must 
be  adapted  to  civilian  problems  and  made  available  for  the 
cripples  of  industry  of  whom  there  are  an  enormous  number. 

MANY  CBIPPLES  FROM  INDUSTBIAX  ACCIDENTS 

It  ie  stated  that  in  eighteen  states,  from  which  we 
have  complete  statistics,  there  are  injured  in  industry 
750,000  persons  per  year,  over  35,000  of  these  accidents 
representing  disability  either  partial  or  total;  and  in  the 
course  of  the  year,  there  are  more  than  28,000  amputations 
^  as  a  result  of  accidents  in  the  entire  country.  No  solution 
of  the  community  health  problem  is  complete  unless  it  takes 
into  consideration  the  training  of  disabled  men,  whether 
such  disability  is  a  result  of  injury  or  disease.  This  problem 
must  of  necessity  vary  in  different  localities. 

There  being,  unfortunately,  comparatively  little  informa- 
tion available  for  the  use  of  the  civilian  community  which 
plana  the  rehabilitation  of  the  industrial  cripple,  it  becomes 
necessary  to  study  what  has  been   done  for  the  disabled 

•HcMortrle.  DengUs  C:   TIi«  Disabled  Soldtor.  New  York.  1019. 


Ci 


130      THE  COMMUNITY  HEALTH  PBOBI»EM 

soldier  and  to  make  xae  of  this  information  in  the  care  of 
the  civilian  cripples. 

The  beginning  of  the  movement  for  the  training  of  soldiers 
was  definitely  established  by  the  organization  of  the  first 
training  school  for  invalided  soldiers  in  Lyons,  France,  in 
December,  1914.  It  is  said  that  Edward  Herriot,  Mayor  of 
Lyons,  noted  that  in  the  streets  of  the  city  there  were  a 
large  nnmber  of  strong  and  nigged  appearing  soldiers  who, 
except  for  a  specific  injury,  appeared  physically  sonnd.  While 
these  men  sat  abont  and  sunned  tliemselves  in  the  sfxeets  of 
the  city  the  nation  cried  for  munition  workers  to  man  the 
nearby  factories.  When  Mayor  Herriot  examined  into  the 
question  of  employing  tiiese  men,  many  of  whom  had  been 
skilled  mechanics,  he  found  that  thqr  were  unable  to  resume 
their  former  occupations  because  of  physical  handicaps. 
It  was  necessary  to  teach  them  new  occupations  before  tiiey 
could  be  employed.  As  a  result  of  his  efforts  a  school  was 
opened  at  Lyons  in  December,  1914,  with  three  pupils.  In  a 
iev  months  it  became  necessary  to  turn  applicants  away. 

With  the  example  of  the  French  before  them  the  move- 
ment soon  spread  to  England,  Bdgium  and  other  allied 
countries. 

Before  the  entry  of  the  United  States  into  the  war  there  had 
been  comparatively  little  study  of  the  vocational  training  of 
cripples  in  this  country.  While  the  need  had  long  been  recog- 
nized, practically  no  serious  effort  had  been  made  to  meet  the 
need  and  very  little  information  as  to  the  character  of  the 
work  being  done  in  France,  Qreat  Britain  and  Italy  was 
available. 

The  first  serious  effort  made  in  America  was  inaugurated 
by  the  Institute  for  Crippled  and  Disabled  Men  which  was 
started  by  the  American  Bed  Cross  in  New  York  City  during 
the  summer  of  1917.  This  was  nearly  a  year  before  the  pro- 
vision for  the  training  of  disabled  soldiers,  sailors  and 
marines  became  a  law  (June  27,  1918).  Vocational  training 
in  the  United  States  was  placed  under  the  supervision  of  the 


BEHABILITATION  OF  THE  DISABLED      181 

already  existing  Federal  Board  of  Vocational  Education,  a 
new  division  of  which  was  created  for  this  purpose  and  termed 
the  Division  of  Behabilitation. 

The  Board  established  offices  throughout  the  country  and 
an  attempt  was  made  to  secure  contact  with  all  injured  sol- 
diers, and  to  approve  for  training  those  who  were  handicapped 
for  their  old  occupations,  and  who  would  benefit  by  a  course  of 
vocational  training.  Unfortunately  there  was  a  great  deal  of 
delay,  due  largely  to  the  fact  that  the  Federal  Board  was 
handling  an  enormous  work  and  that  it  was  practically 
impossible  to  secure  for  the  divisional  offices,  employees  who 
had  been  trained  in  work  of  this  sort.  Consequently  the  train- 
ing of  many  disabled  men  was  delayed  for  weeks,  or  months 
tluroTigh  no  fault  of  their  own. 

EABLY    TBAININQ    NBCES8ASY 

Training  should  start  before  the  patient  is  discharged  from 
the  hospital.  This  is  very  important  and  is  too  often 
neglected.  During  the  long  period  of  convalescence  the  sol- 
dier becomes  tired  of  the  monotonous  existence  he  is  forced 
to  undergo.  He  smokes  too  much,  is  apt  to  drink  too  freely 
and  is  generally  at  odds  with  his  surroundings.  Healthful 
daily  occupation  not  oply  aids  in  dispelling  ennui  but  actu- 
ally hastens  healing.  This  part  of  the  work  must  necessarily 
be  undertaken  in  an  institution  where  teaching  facilities  for 
a  large  number  of  pupils  can  be  easily  secured.  Medical 
attention  must  also  be  available  so  that,  when  dressings  are 
required,  only  a  small  amount  of  time  need  be  lost.  It  is  not 
necessary  for  all  the  men  to  live  at  the  institution,  many 
can  live  at  home  and  take  the  daily  trip  back  and  forth  for 
medical  care  and  instruction.  Only  in  very  exceptional  cases 
should  men  be  permitted  to  enter  ordinary  schools  until  the 
maximum  benefit  from  medical  treatment  has  been  obtained. 

The  United  States  law  failed  to  insist  upon  hospital  train- 
ing, so  that,  as  a  consequence,  after  the  patient  left  the  hos- 
pital there  was  a  grievous  delay  before  vocational  training 


132      THE  COMMUNITY  HEALTH  PBOBLEM 

could  be  startecL  This  was  laigelj  doe  to  the  oyerwhehniag 
of  the  Federal  Board  with  more  dases  than  thej  could  pos- 
sibly handle,  and  to  other  canses  which  apparently  are  inher- 
ent in  goTenunent  undertakings.  The  Medical  Depart- 
ment of  the  Army,  or  Navy,  discharged  the  man,  when  in  the 
opinion  of  the  surgeons  the  maximnm  benefit  had  been 
attained.  He  then  had  to  apply  to  the  War  Bisk  Insorance 
Bureau  for  a  pension  and  to  the  Federal  Board  for  vocational 
training.  This  required  applications,  proofs  of  identity, 
repeated  medical  examinations  and,  as  a  consequence,  long 
delays  in  many  cases.  This  has  caused  much  criticism  of  tiie 
Federal  Board.  The  discharged  soldier  felt,  not  without  rea- 
son, that  he  was  not  receiving  a  square  deal.  When  he  vns 
asked  to  go  over  the  top  and  risk  his  life  it  was  not  necessary 
to  wait  for  a  special  conmiunication  from  Washington.  Why 
should  there  be  so  much  delay  when  the  country  was  asked  to 
repay  the  debt?  As  the  work  has  progressed  the  machinery 
of  the  law  is  acting  more  smoothly  and  there  has  been  less 
cause  for  complaint. 

PHTSICIAN    FLATS    IMPOBTAITP   PABT 

The  role  of  the  physidan  in  the  training  of  the  war  crip- 
ple is  an  important  one.*  In  the  first  place  the  physician 
must  pass  on  the  physical  condition  of  the  applicant,  to 
decide  if  he  has  actually  obtained  the  maximum  benefit  from 
treatment  If  no  further  treatment  is  required  it  is  neces- 
sary to  decide  whether  his  disability  actually  disqualifies  him 
for  foUowing  his  old  occupation.  It  is  not  enough  to  con- 
clude that  he  may,  by  extra  effort,  continue  in  his  old  employ- 
ment. The  questions  must  be  asked,  **If  this  man  returns  to 
his  old  occupation  will  he  be  handicapped  as  compared  with 
the  normal  worker?"  and  '"Will  this  man,  if  he  returns  to  his 
old  work,  be  able  to  carry  on  as  long  as  the  normal  worker?" 

•Th«  author  has  dlacnssed  fhia  phasa  of  tha  anbjaet  mora  L^«tan 
In  an  article  entitled  Behabllltatloa  In  it*  BaUtlon  to  tha  FhjtkiMa, 
Modem  Medidne,  Febniar7>  lB2a 


EEHABILITATION  OF  THE  DISABLED      133 

If  he  compares  tmfavorably  with  the  normal  worker  it  is 
necessary  to  give  the  man  some  form  of  training  so  that,  by 
his  skill,  he  may  be  able  to  compete  with  the  normal  worker 
on  equal  or  nearly  equal  terms.  Thus,  a  mechanic  may  be 
taught  special  mechanical  processes  which  require  special 
technic,  tilius  making  it  easy  for  him  to  secure  employment 
in  spite  of  a  wooden  leg  or  a  partially  crippled  arm.  That  is, 
the  man  may  be  given  additional  training  in  his  old  occu- 
pation if  this  is  considered  practicable.  This  is,  however,  not 
always  possible.  A  policeman  who  had  both  feet  frozen  was 
found  no  longer  fit  for  his  old  occupation  and  consequently  it 
was  necessary  to  train  him  in  an  entirely  new  line  of  work. 
He  became  a  wireless  operator.  A  physician  became  stone 
deaf  as  a  result  of  a  shell  explosion  which  left  him  otherwise 
uninjured.  This  disability  made  it  impossible  for  him  to  con- 
tinue private  practice  but  he  was  trained  as  a  laboratory 
worker,  and  was  able  to  take  full  charge  of  a  hospitd 
laboratory. 

In  the  choice  of  a  vocation,  the  man  consults  with  the 
vocational  advisor  and  between  them  they  come  to  an  under- 
standing which  is  based  upon  the  man's  previous  education 
and  training,  his  desires,  the  openings  available  and  the  opin- 
ion of  the  advisor  as  to  the  man's  aptitude  and  capabilities. 
After  the  dioice  is  made  the  man  is  sent  to  the  medical  ad- 
visor to  decide  whether  there  is  any  objection  from  a  physical 
standpoint  to  the  proposed  course  of  training. 

In  the  United  States  every  disability,  whether  due  to  in- 
jury or  disease,  which  arose  from,  or  was  increased  by  mili- 
tary service,  is  to  be  considered  from  a  vocational  view- 
point The  handicap  from  a  vocational  standpoint  is  classi- 
fied either  as  major,  minor  or  negligible.  If  there  is  a  major 
handicap,  according  to  the  Act,  the  man  receives  training 
and  an  allowance  for  expenses  varying  from  $80  to  $116 
monthly,*  depending  upon  the  number  of  dependents  who  look 
to  him  for  support.    A  minor  handicap  entitles  a  man  to 

•This  amonnt  la  Bometlmes  increased  by  the  Federal  Board. 


r 


134      THE  COMMUNITY  HEALTH  PBOBLEM 

training,  bnt  to  no  allowance,  and  a  negligible  handicap 
entitles  him  to  placement  in  a  position  but  no  allowance  and 
no  training. 


OLASSHTOATION    07    HAin)ICAP 

The  instmctions  issued  by  the  Federal  Board  on  this  point 
are  as  follows : 

(a)  '^Major  Handicap"  inclndes  cases  in  which,  from  the 
point  of  view  of  the  entry  in  question,  the  disability  will  be  a 
real  and  permanent  handicap  in  the  occupation  such  as  to 
effect  employability  and  earning  power. 

(b)  **Minor  Handicap*'  inclndes  cases  in  which,  from  the 
point  of  view  of  the  entry  in  question,  disability  involves 
some  inconvenience  that  does  not  interfere  in  any  real  way 
with  the  employability  or  earning  power  and  that  frequently 
may  become  negligible  after  a  brief  experience  in  the  vocac 
tion. 

(c)  '^Negligible  Handicap**  inclndes  cases  in  which,  from 
the  point  of  view  of  the  entry  in  question,  the  disabili^  may 
be  disregarded  in  coxisidering  the  man's  employability  and 
earning  power. 

In  some  cases  the  question  of  handicap  presents  a  difficult 
problem.  Especially  is  this  so  of  those  who  complain  of  dis- 
ability with  indefinite  or  ill  defined  symptoms.  In  such  cases 
the  District  Medical  Officer  may  send  the  man  to  a  specialist 
for  consultation,  to  a  radiographer  for  an  X-ray  or  to  a  labo- 
ratory for  a  special  analysis.  Here  the  physician  has  at  his 
command  all  the  methods  required  by  modem  practice 
for  the  diagnosis  of  disease.  For  example,  a  man  com- 
plains of  weakness  in  his  hand  following  a  gunshot  wound  of 
the  arm.  A  neurological  examination  shows  that  he  has  a 
partial  paralysis  of  one  of  the  nerves  of  the  arm  and  that  his 
disability  is  probably  permanent  Such  a  man  will  be  classed 
as  a  major  handicap.  Another  complains  of  pain  in  the  elbow 
when  the  elbow  is  bent,  following  an  old  fracture.  An  X-ray 


^ 


BEHABILITATION  OF  THE  DISABLED      136 

of  the  elbow  shows  a  small  spicule  of  bone  projectmg  into 
the  joint.  Operation  is  not  considered  advisable  and  the  man 
is  given  a  ''major  handicap,  probably  permanent." 


ICEDIOAL    ATTENTION     NEOESSABY     DUSINO     TBAIKINO 

(Any  plan  for  vocational  training  should  include  medical 
attention  for  the  man  during  the  period  of  training.  Under 
the  plan  adopted  in  this  country  this  care  is  given  by  the 
U.  S.  Public  Health  Service.  This  has  not  worked  very  well 
because  the  applicant  is  not  in  touch  with  the  Public  Health 
Service,  as  a  rule,  and  the  physicians  of  this  service  are,  in 
turn,  not  in  close  touch  with  the  Federal  Board.  It  is  a  ques- 
tion if  better  results  would  not  have  been  obtained  if  the  entire 
work  had  been  undertaken  by  a  medical  organization  such 
as  the  Medical  Department  of  the  Army  or  the  U.  S.  Public 
Health  Service,  instead  of  dividing  the  medical  care  and 
educational  supervision  between  the  Public  Health  Service, 
on  the  one  hand,  and  the  Federal  Board,  on  the  other.  At 
present  there  is  considerable  duplication  of  effort  Many  of 
the  difficulties  of  the  Federal  Board  arise  because  of  this 
duplication  and  because  of  the  enormous  amount  of  work 
which  it  handles.  With  untried  methods  and  inexperienced 
employees,  many  mistakes  were  certain  to  occur  in  the  rush 
of  applicants,  beginning  directly  after  the  armistice,  which 
would  not  occur  in  a  community  effort  on  a  small  scale. 

There  is  a  problem  of  considerable  human  interest  in  tho 
examination  of  applicants  for  training.  There  may  be  seen 
some  of  the  terrible  results  of  war,  met  with  a  spirit  of  brav- 
ery and  heroism  worthy  of  the  cause.  Some  men  appear 
determined  to  belittle  their  disability  and  have  to  be  argued 
into  accepting  training.  Such  men  succeed  with  a  small 
amount  of  help  and  guidance.  On  the  other  hand,  cases  are 
seen  in  which  a  simple  injury  with  no  apparent  disability  has 
so  unsettled  the  soldier^s  mind  that  he  is  unable  to  undertake 
any  form  of  vocational  education.  These  latter  are  the  hard- 


136      THE  COMMUNITY  HEALTH  PBOBLBM 

est  cases  to  deal  with,  the  men  being  menially  unsettled  and 
not  to  be  depended  npon.  It  is  hoped  that  in  time  they  Trill 
find  themselves  and  become  useful  citizens. 
The  following  three  cases  are  typical : 

F.  B.  24  Tears— Sergt.  n^d  ArtUlerx.  Irish  ptMBtafiL  Baltetad 
April  19,  1017.  Discharged  Oct.  7,  1919.  Dlagnoala:  Old  acar  (oUowinc 
mastoid  operation,  left  side.  In  hospital  9  months.  Diacharcid  ttom 
hospital  Oct  7,  1019.     DlsabUltj:     Deafneaa  left  ear.     Preriona  occa- 

?atfon:  Btndent,  self  anpportlng.  Unable  to  continue  conrae  for  lack  of 
unds.  In  this  case  the  handicap  is  considered  as  25  per  cent.  If  thla 
man  la  allowed  to  complete  bis  course  in  electrical  engineering,  he  wUl 
be  able  to  overcome  his  handicap.  Becommended  for  conraa  la  ICaiaa- 
chnaetta  Institute  of  Technology. 

B.  W.  24  years — Serbian  parentagei  Bnllated  in  Infantry.  December, 
1917.  Wounded — Jnly,  1918.  In  XL  8.  Army  hospitals  eleven  months. 
Discharged  Jnne.  1919.  War  Risk  Borean  gives  diaabiUty  aa  75  per 
cent.  Previous  occupation — laborer.  Kxaminatlon  ahows  multiple  gun- 
shot wounds  completely  healed.  Complete  blindness  right  eye,  follow* 
Ing  wound  of  temple.  Deformity  of  right  hand  following  G.  8.  W.  la 
unable  to  use  hand  for  liner  movements  but  baa  strong  grip  and  will  b« 
able  to  do  heavy  work.  New  occupation  advised — ^vulcanlxing.  This  maa 
will  be  sent  to  a  trade  school  to  learn  vulcanizing.  As  a  skilled  worker 
be  should  receive  more  par  than  previously  and  be  able  to  overcoma 
his  handicap.  As  a  laborer  be  would  probably  end  by  becoming  a  charge 
on  the  community. 

R.  8.  G.  26  years— American — First-clasa  seaman.  BnUsted  November, 
1917.  Served  as  armed  guard  on  commercial  liner.  Discharged  January, 
1919.  Old  occupation— mach Inisf a  helper.  Diagnosis  (Feb..  1919): 
Nephritis,  chronic  parenchymatous.  DisabUlty  complete,  unable  to  per- 
form any  work.  Referred  to  Marine  Hospital,  Staten  Island,  for  treat- 
ment Oct  8,  1019:  lian  has  been  In  hospital  for  nearly  eight  months. 
Betums  anxious  to  go  to  work.  Examination  shows  that  he  ia  stlU 
suffering  from  nephritis  and  able  to  do  only  very  Ught  work.  If  this 
man  does  hard  work  his  trouble  will  be  aggravated  and  he  wiU  becom* 
a  charge  on  the  community.  He  should  be  sent  away  where  he  caa  do 
Ught  work  and  be  under  medical  aupervlaion. 

When  the  work  of  the  Federal  Board  is  finished  an  enor- 
mous amount  of  statistical  data  will  be  available  both  from  a 
medical  and  a  vocational  standpoint  In  instituting  vocational 
training  for  industrial  cripples  the  experience  of  the  Federal 
Board  should  be  made  use  of,  mistakes  being  avoided  by  a 
careful  study  of  methods  employed  by  the  board  and  of  the 
experiences  of  foreign  countries  in  the  same  field. 

For  those  who  are  interested  in  this  phase  of  social  welfare 
work  the  government  publishes  a  monthly  magazine^  the 
Vocational  Summary,  which  may  be  secured  by  application  to 
the  Federal  Board  of  Vocational  Education,  Washington, 
D.C. 

*  The  case  Ustortss  and  a  part  of  this_chapter^deallng  especially  with 
_le  medical  aspects  of  the  work  of  "' 
permlsBlon,  from  an  article  by  the 


the  medical  aspects  of  the  work  of  the  Federal  hoard,  are  reprinted.  Vr 
le  author  In  Modem  Medicine,  Feb.,  1020. 


BEHABILITATION  OF  THE  DISABLED      137 

BSHABZLZTATIOK    OF   THE    OIYILIAK    OSIPFLB 

WLUe  the  training  of  the  disabled  soldier  has  been  care- 
fully worked  out  the  training  of  the  crippled  civilian  is  pass- 
ing throngh  the  formative  period,  so  that  it  is  difficult  or 
impossible  to  outline  its  present  status.  What  is  true  at  the 
time  this  is  written  may  be  changed  before  it  appears  in 
print.  It  is  therefore  impossible  to  make  definite  statements 
in  reference  to  the  details  of  the  movement. 

In  genera],  the  Federal  Government  plans  to  encourage 
the  development  of  re-education  for  industrial  cripples 
through  an  appropriation,  a  part  of  which  is  made  available 
to  the  various  states  upon  the  condition  that  they  appropri- 
ate a  similar  amount  and  carry  out  the  details  of  the  work 
in  accordance  with  definite  standards  established  by  the  Fed- 
eral Board.  Many  states  are  co-operating  in  this  work  but 
the  methods  of  procedure  have  not  yet  been  worked  out. 

It  is  the  opinion  of  the  writer  that  civilian  methods  of 
vocational  re-education  can  be  most  successfully  developed  in 
the  various  states,  through  the  grouping  of  the  disabled  work' 
crs  in  certain  definite  localities  for  training.  This  will  per- 
mit the  grouping  of  students  and  instructors  in  an  institu- 
tion and  will  thus  allow  for  a  more  direct  contact  between 
the  student  and  the  trained  instructor.  In  other  words  it  is 
believed  that  one  or  more  schools  should  be  established  in 
appropriate  locations  in  each  state,  rather  than  to  attempt 
to  provide  instruction  in  various  already  existing  industrial 
establishments,  where,  in  many  cases,  as  has  been  shown  by 
experience,  the  training  of  disabled  workmen  has  become  side- 
tracked by  the  pressure  of  routine  work. 

Each  institution  should  provide  facilities  both  for  func- 
tional re-education,  that  is  the  training  of  the  muscles  to 
overcome  as  far  as  possible  the  physical  handicap,  and  voca- 
tional re-education  or  the  training  of  the  disabled  worker  for 
a  new  vocation.  Functional  re-education  falls  naturally  under 
the  supervision  of  an  orthopedic  surgeon,  while  vocational 
training  would  be  under  the  control  of  those  skilled  in  voea- 


138      THE  COMMUNITY  HEALTH  FBOBIiEM 

tional  subjects.  Often  these  two  forms  of  re-education  maj 
be  carried  on  at  the  same  time. 

After  the  institutional  training  has  been  completed,  the 
student  may  be  profitably  sent  out  for  a  period  of  practical 
field  experience. 

Until  statewide  plans  are  carefully  worked  out,  commun- 
ities may  attempt  to  secure  training  for  industrial  cripples 
in  various  local  industries.  In  a  few  cases  this  has  been  yeiy 
successful  but,  in  the  main,  if  there  is  a  school  available  for 
this  purpose  within  the  state,  much  better  results  may  be 
expected  to  follow  the  institutional  plan  of  training  than  can 
be  hoped  for  uder  asy  f oim  of  local  commimily  effort 


CHAPEB  XVI 

ENDOWED  HEALTH  DEMONSTRATIONS* 

Tlie  methods  employed  by  the  Rockefeller  Foimdatioii  are 
of  interest  to  students  of  communily  health  because  the  enor- 
mous financial  resources  of  the  organization  permit  it  to 
make  experiments  in  health  control  which  for  economic  rea- 
sons could  seldom  be  attempted  by  the  average  community. 

Jks  expressed  in  its  charter  the  purpose  of  the  Eockefeller 
Foundation  is  the  promotion  of  **the  welfare  of  mankind 
throughout  the  world."  This  is  a  big  undertaking  even  for 
an  organization  with  an  endowment  fund  of  over  one  hun- 
dred million  dollars  and  a  yearly  income  which,  including 
gifts,  amounted  to  $8,609,710.86  in  1918. 

In  order  to  secure  the  greatest  benefit  from  this  income 
the  trustees  of  the  Foundation  have  followed  a  program  of 
education  and  diffusion  of  knowledge  so  that  each  country 
may  "contribute  its  best  achievements  to  a  common  fund 
from  which  all  lands  may  draw/'  In  the  report  for  1918  it  ia 
stated  that,  "in  this  commerce  of  culture,  science,  sympathy 
and  idealism,  the  RockefeDer  Foundation  desires  to  put  its 
policies,  personnel  and  resources  at  the  service  of  the  world.** 

The  Eockefeller  Foundation  bears  the  same  relation  to*A 
public  health  as  a  state  agricultural  college  does  to  farming.  / 
The  Foundation  may  indicate  methods  for  health  improve- 
ment, and  even  actually  put  such  methods  into  practice  in 
certain  selected  communities,  but  in  the  main  it  has  always 
been  the  desire  of  this  organization  to  withdraw  from  the 
field  when  adequate  methods,  whether  for  prevention  or 
cure,  are  once  established  on  a  firm  working  basis  by  local 
authorities. 

During  the  year  1918  large  amounts  were  expended  for 

*TIi«  BtatiBtlcB  tn  this  chapter  wcrA  taken  In  part  from  th«  Annwal 
Heports  of  the  Eockefeller  FouadaUon.  1017  and  191& 

139 


^ 


140      THE  COMMUNITY  HEALTH  PEOBLEM 

war  relief  largely  through  the  American  Bed  Cross,  and 
the  United  War  Work  Fund  of  the  Young  Men's  Christian 
Association.  These  two  organizations  received  over  $9,600,000 
during  the  war  and  ahout  $1,000,000  in  addition  was  devoted 
to  other  organizations.  During  the  same  year  approximately 
$350,000  was  appropriated  for  medical  research  and  relief 
in  connection  with  war  activities. 

In  spite  of  this  tremendous  sum  which  was  spent  for  war 
relief,  the  regular  expenditures  for  public  health,  medical 
education  and  research  amounting  to  $3,600,000  were 
continued. 

From  the  standpoint  of  community  health  the  greatest 
interest  is  found  in  the  work  of  the  campaign  against  tuberco* 
losis  in  France,  the  work  of  the  International  Health  Board, 
and  the  researches  of  the  Bockefeller  Institute  of  Medical 
Kesearch. 

THB  FBENCH  CAMPAIGN  AGAINST  TUBEE0UL08I8 

The  campaign  against  tuberculosis  in  France,  as  has  been 
pointed  out  by  Dr.  George  E.  Vincent,  President  of  the  Foun- 
dation, was  not  undertaken  because  the  French  are  less  skilled 
in  the  treatment  of  tuberculosis  or  because  the  scientific 
knowledge  of  the  disease  in  France  is  second  to  any  o&er 
country.  It  was  found  that  in  France  there  were  sanitorii 
which,  as  regards  buildings,  scientific  equipment,  personnel 
and  surroundings,  were  as  good  if  not  better  than  anything  to 
be  found  in  America.  The  Leon  Bourgeois  Dispensary  in 
Paris  was  found  well  organized,  with  visiting  nurses,  trained 
physicians,  free  public  lectures,  and  everything  that  goes  to 
make  up  a  modem  scientific  dispensary. 

If  America  had  anything  to  contribute  to  the  French  it 
was  a  demonstration  of  organized  team  work.  In  France 
ideas  do  not  spread  so  rapidly  as  they  do  in  this  country, 
possibly  because  there  are  few  national  organizations  whicfi 
can  quickly  inform  each  community  what  is  being  done  in 
every  other. 


ENDOWED  HEALTH  DEMONSTRATIONS     141 

There  has  been,  in  France,  a  rapidly  iifcreasing  interest  in 
the  question  of  public  health  since  the  work  was  begun. 
Clever  advertisements  were  read  by  all  and,  partly  because  of 
•  the  advertisements  themselves  and,  partly  because  the  advertis- 
ing of  public  health  was  a  new  idea  which  originated  with  "les 
Americains,**  the  movement  created  great  interest.  Work  was 
begim  intensively  in  two  communities  and  gradually  increased 
until,  at  the  end  of  1918,  the  campaign  had  been  extended  to 
twenty-seven  departments.  Prench  visiting  nurses,  les  vis- 
iteuses  d'hygikne,  were  trained  at  the  various  dispensaries  and 
arrangements  made  to  bring  a  group  of  physicians  to  the 
United  States  to  give  them  an  opportunity  to  study  American 
institutions  and  methods.  In  the  yearly  report  the  following 
statement  is  made  in  reference  to  the  campaign  against 
tuberculosis  in  France :  '^Within  a  reasonable  time,  therefore, 
the  Foxmdation  expects  to  withdraw,  confident  that  the  work 
will  go  on  until  a  nationwide  system  of  combating  tubercu- 
losis has  become  a  permanent  part  of  the  policy  of  Prance." 

The  method  of  handling  this  campaign  is  typical  of  much 
of  the  work  done  by  the  Eockefeller  Foundation.  To  move  in, 
to  create  interest,  to  demonstrate  what  can  be  done  by  a  rea- 
sonable expenditure  of  time  and  money,  and  then  to  withdraw 
and  leave  the  work  to  be  carried  on  by  local  organizations 
apparently  is  the  general  policy. 

THB    HEALTH    OAHPAION    IN    KOBTH    OASOLDTA 

This  policy  is  also  seen  in  the  work  done  in  North  Caro- 
lina in  conjunction  with  the  State  Department  of  Health.  A 
three-year  program  was  laid  out,  the  appropriations  gradu- 
ally decreasing  during  the  period.  North  Carolina  was  the 
first  state  in  the  South  to  attempt  to  meet  its  rural  health 
problems  by  effective  organization  on  a  counly  basis.  Cam- 
paigns have  been  carried  out  against  typhoid  fever,  hook- 
worm, dysentery  and  many  other  diseases.  Child  welfare,  the 
prevention  of  tuberculosis  and  the  medical  inspection  of 
school  children  are  all  included  in  the  plan.  The  State  Board 


142      THE  COMMUNITY  HEALTH  PBOBLEM 

of  Heall^  is  in  cbarge^  the  local  vork  Is  largely  done  by  Uie 
connly  health  anthorities  and  the  expenses  are  met  by  the 
state,  the  connties,  and  the  Bockefeller  Fotmdation.  After 
three  years  the  Fonndation  is  to  withdraw  and  the  program 
is  to  be  eontinned  by  the  connties  and  the  state. 

This  experiment  in  North  Carolina  will  bear  farther 
watching.  It  is  proposed  to  see  that  every  child  attending 
school  receives  any  necessary  medical  treatment  which  may 
be  required.  Trips  are  made  to  ont  of  the  way  districts  so 
that  all  cases  may  receive  treatment  and  the  effort  gives 
promise  of  excellent  results. 

The  experience  in  the  prevention  of  typhoid  fever  has  been 
most  instxuctive.  "In  nine  connties  of  Nortii  Carolina,  dnr- 
ing  the  four  year  period  from  1914  to  1917  the  total  deaths 
from  typhoid  fever  were  478.  This  is  a  yearly  average  of 
119.5  deaths,  or  35.3  deaths  per  hundred  thousand.  During 
1918  as  a  result  of  a  crusade  against  soil  pollution  in  these 
nine  connties,  a  total  of  6,480  fly-proof  privies  were  erected. 
Typhoid  fever  statistics  for  the  year  1918  show  that  ont  of  an 
aggregate  population  of  305,016  in  these  counties  there  were 
only  24  deaths  from  this  disease,  a  rate  of  7.8  per  hundred 
thousand. 

It  is  possible  that  North  Carolina  will  actually  solve  some 
of  the  more  troublesome  problems  of  community  health  while 
the  northern  states  are  still  discussing  them.  The  experi- 
ment is  one  of  widening  influence  of  the  state  in  the  domain 
of  health  and  approaches  state  medicine.  So  far,  in  North 
Carolina  at  least,  the  venture  has  been  most  successful 

The  Bockefeller  Foundation  is  using  its  influence  to 
advance  medical  education.  The  School  of  Hygiene  and  Pub- 
lic Health  at  Johns  Hopkins  was  organized  largely  through  its 
efforts  and  a  similar  school  has  been  organized  in  connection 
with  the  medical  university  at  San  Paulo,  Brazil.  Students 
from  Brazil,  China  and  France  have  been  granted  fellowships 
in  order  to  study  in  the  United  States  and  members  of  the 
medical  staff  of  the  Foundation  are  granted  "atady  leave"  in 


ENDOWED  HEALTH  DEMONSTRATIONS      143 

order  to  ptirsue  special  courses  in  public  health  at  leading 
American  or  foreign  institutions.  In  China  a  medical  school 
is  now  in  course  of  construction. 

HOOKWOBM    DTPEOnON 

For  several  years  experiments  have  been  conducted  in  an 
effort  to  combat  hookworm  infection.  This  disease,  widely 
prevalent  in  our  southern  states,  has  been  found  to  be  of 
almost  worldwide  occurrence.  Hookworm  disease  exists  wher- 
ever the  larvae  of  the  worm  find  favorable  soil  conditions. 
They  require  shade,  moisture  and  warmtii  for  their  propaga- 
tion and  growth  such  as  found  in  tropical  or  subtropical 
countries.  They  are  not  found  in  cold  countries  or  in  very 
dry  countries,  such  as  Arizona  or  northern  Mexico. 

In  India,  Brazil,  the  West  Indies,  Central  America  and 
Australia,  widespread  infection  has  been  demonstrated  by 
the  work  of  the  International  Health  Board.  In  many  of  the 
areas  studied,  between  80  and  100  per  cent,  of  all  inhabitants 
"Were  found  infected.  Work  done  by  IT.  S.  Army  surgeons 
during  the  recent  war  indicated  that  a  large  percentage  of 
southern  troops,  both  white  and  colored,  were  suffering  from 
hookworm  infection  of  more  or  less  pronounced  degree. 

Hookworm  disease  results  from  the  presence  of  hookwonns 
in  the  human  intestine.  It  begins  insidiously  and  may  not 
make  itself  felt  for  several  years.  For  a  time  the  body  is 
able  to  resist  the  disease,  but  the  cumulative  effect  finally 
becomes  evident.  The  physical  strength  is  slowly  sapped  by 
imperceptible  degrees,  so  that  there  is  finally  a  distinct 
retardation  of  physical  development  and  the  mental  capacity 
is  gradually  undermined,  tiie  result  being  that  in  the  later 
stages  the  impairment  of  the  intellectual  character  is  plainly 
evident.  Anemia,  loss  of  flesh  and  strength,  and  defective 
mentality  are  the  characteristic  symptoms.  Persons  suffering 
from  the  infection  although  showing  few  if  any  sjrmptoms 
are  more  susceptible  to  other  infections  than  are  healthy 
individuals.    In  Camp  Bowie  the  sickness  records  &om  Octo- 


144      THE  COMMITNITY  HEALTH  PEOBLEM 

ber,  1917,  to  M&y,  1918,  demonstrated  that  lesistaiice  to 
other  diseases  was  the  lowest  and  mortality  rates  were  the 
highest  in  those  organizations  in.  which  hookworm  disease  was 
the  most  prevalent.  ( 

The  diagnosis  is  easily  made  from  the  examination  of  the 
stools  and  the  core  is  simple,  being  accomplished  often  bj  a 
single  treatment  with  a  strong  intestinal  antiseptic  followed 
by  a  purge.  Yet  in  spite  of  tiiis  there  are  hnge  districts  in 
the  Unit^  States  where  no  concerted  efforts  have  been  made 
to  rid  the  commnnity  of  the  affiction. 

IKTEOnON  8UBYET  OF  JAHAIGA* 

9 

The  methods  of  the  International  Health  Board  may  6e 

illustrated  by  the  following  survey: 

The  infection  survey  of  the  Cayman  Islands  (a  dependency 
of  Jamaica)  made  during  the  spring  of  1917,  resulted  in  the 
Government  appropriating  approximately  $12,000  for  carry- 
ing out  a  co-operative  campaign  against  hookworm  disease  in 
Jamaica  proper.  As  an  initial  step  in  the  measure  of  control, 
an  infection  survey  of  the  Island  was  made  during  June  and 
July,  1918.  ( 

The  survey  indicated  that  probably  two  of  every  three 
inhabitants  of  Jamaica  have  hookworm  disease.  High  infec- 
tion rates  were  also  recorded  for  round  worms  and  thread 
worms,  the  former  being  found  in  67.2  per  cent,  of  10,926 
persons  examined,  and  the  latter  in  35.9  per  cent.  In  the 
larger  towns  and  cities,  which  are  located  along  the  coast,  a 
beginning  has  been  made  toward  the  proper  disposal  of  the 
excrement,  but  in  the  rural  districts  soil  contamination  is 
practically  universal.  There  are  laws  requiring  a  latrine  at 
every  home,  but  no  serious  attempt  has  been  made  to  enforce 
them. 

r 
I27AnGl7Si.Tn>N     OP     CONTROL     MEABTTBBS 

The  survey  is  to  be  followed  by  a  series  of  demonstrations 
in  codttol  measures.  The  working  arrangement  provides  tiist 

<^               •Fram  til*  Appendix  of  tlt«  Beport  for  WB.    BockeWhr  VwaAafSan, 
^  ^\  K«wTefrlt.  _ . _ 


ENDOWED  HEALTH  DEMONSTEATIONS     145 

the  €k>verninent  is  to  sliare  the  expense  of  the  mitial  field 
posts  and  to  have  suitable  latrines  installed  in  all  areas  in 
advance  of  examination  and  treatment.  The  (Government  has 
available  approximately  $7^500  as  a  first  appropriation  for 
this  purpose. 

It  iB  to  be  expected  that  the  Foundation  will,  in  a  case  such 
as  the  above,  furnish  the  funds  and  personnel  for  the  proper 
demonstration  of  the  control  of  the  disease  in  one  or  mora 
sections  of  the  Island,  leaving  the  balance  of  the  Island  to 
be  cared  for  by  the  Grovemment.  Complete  control  of  the 
disease  is  diflScult  and  the  prevention  of  reinfection  is  impos- 
sible unless  modem  sanitation  is  introduced  and  maintained. 

THE    OONTBOL    OF    ItfALARTA 

The  Foundation,  through  the  International  Health  Board, 
has  carried  out  a  series  of  demonstrations  on  the  control  of 
malaria  in  various  localities.  We  know  that  malaria  is  car- 
^lied  by  a  certain  species  of  mosquito  and  we  know  that  if  we 
can  eliminate  the  mosquito  the  spread  of  the  disease  will 
automatically  stop.  This  has  been  known  for  many  years  ^d 
yet  there  are  literally  thousands  of  communities  which  are 
afSicted  with  this  disease  and  yet  make  no  concerted  effort  to 
be  rid  of  it.  It  has  remained  for  the  Eockefeller  Foundation 
to  demoostrate  that  it  is  cheaper  to  be  rid  of  malaria  than  to 
have  it. 

EXPBBIMBNT  AT  CBOSSET^  ABKAITOAS,   1916* 

The  first  of  the  tests  was  undertaken  at  Cresset,  a  lumber 
town  of  2129  inhabitants  situated  in  Ashley  County  in  south- 
eastern Arkansas,  about  twelve  milee  north  of  the  Louisiana 
line.  It  lies  at  the  edge  of  the  ''uplands"  in  a  level,  low  lying 
region  (elevation  165  feet)  with  sufficient  tindulation  to  pro- 
vide reasonably  good  natural  drainage.  Climatic  conditions 
and  abundant  breeding  places  favor  the  growth  of  the  ano- 
pheles mosquito.   Malaria  in  a  severe  form  w  widely  preva- 

•Qa6t«d  from  tli«  B«pdrt  for  tUS.  ..^^^.< 


146       THE  COMMUNITY  HEALTH  PBOBLEM 

lent  as  an  endemic  infection  and,  according  to  the  estimate 
of  the  local  physicians,  is  responsible  for  about  60  per  cent 
of  all  illness  tbronghont  the  region.  Within  the  town  itself 
the  malaria  rate  was  high  and  was  recognized  by  the  lumber 
corporation  and  the  people  as  a  serions  menace  to  health 
and  working  efSciency. 

The  initial  step  in  the  experiment  was  a  survey  of  the  com" 
munity  to  determine  the  malarial  incidence,  to  ascertain  the 
species  of  mosquitoes  responsible  for  the  spread  of  the  infec- 
tion and  to  locate  the  breeding  places  of  these  mosquitoes. 
Breeding  places  were  exhibited  on  a  communify  map,  and  an 
organized  effort  was  centered  on  their  destruction  or  control. 
The  program  of  simple  measures  excluded  all  major  drain- 
age. Shallow  ponds  were  filled  or  drained;  str^uns  were 
cleared  of  undergrowth  where  necessary  to  let  the  sxmlight  in; 
their  margins  and  beds  were  cleared  of  vegetation  and  obstruc- 
tions ;  and  they  were  drained  to  a  narrow  channel  pro- 
viding an  unobstructed  water  flow.  Artificial  containers  were 
removed  from  premises ;  water  barrels  on  bridges  were  treated 
with  nitre  cake.  All  remaining  breeding  places  were  regu- 
larly treated  by  removing  vegetation,  opening  up  shallow  mar- 
gins to  give  free  access  to  small  fish,  and  spraying  once  a 
week  by  means  of  automatic  drips  or  a  knapsack  sprayer.  All 
operations  were  under  the  control  of  a  trained  lay  inspector. 
Care  was  exercised  to  avoid  all  unnecessary  effort,  and  to  se- 
carej  not  the  elimination  of  the  last  mosquito  but  a  reason- 
ably high  degree  of  control  at  a  minimum  ccet. 

The  first  conspicuous  result  apparent  to  every  person  living 
in  the  communify  was  the  practical  elimination  of  the  mos- 
quito as  a  pest.  The  reduction  of  malaria  as  shown  by  a 
parasitic  index  taken  in  May,  1916,  and  again  in  Deceniber 
of  the  same  year,  was  72.33  per  cent.  The  reduction  in  phy- 
sicians' calls  as  compared  with  the  number  of  calls  for  the 
previous  year  (company's  record)  was  70.36  per  cent.  Tfie 
per  capita  cost  of  the  work — omitting  overhead — ^was  $1.24. 
During  the  year  the  lumber  company  had  repeated  these 


ENDOWED  HEALTH  DEMONSTRATIONS     147 

meaatnes  at  two  of  its  large  logging  camps  with  resnlts  that 
were  convincing  as  to  the  soundness  of  the  investment. 

At  the  end  of  1916  the  commnnity  took  over  the  work  and 
for  two  years  has  maintained  it  at  its  own  expense  and  nndei 
its  own  direction.  The  same  measures  have  been  continued 
nnder  the  supervision  of  a  trained  native  lay  inspector.  The 
following  table  shows  the  yearly  results  and  the  per  capita 
cost: 

PHYSICIANS     GALLS    FOB    TtfALARTA 

Population  2129 
1916  Calls  (Company's  records)  2500 

1916  «  "  741 

1917  "  "  200 

1918  «  "  73 
Beduction  for  the  three  years,  97.1  per  cent. 

PEE   CAPITA   COST 

1916  (omitting  overhead)  $1.24 

1917  (total  cost)  .63 

1918  (total  cost)  .63 

These  results  were  confirmed  in  other  localities  where  dm- 
ilar  figures  were  obtained. 

The  methods  used  by  the  Bockefeller  Foundation  have 
been  described  in  some  detail  in  order  to  give  some  idea 
as  to  what  may  be  accomplished  in  a  community  by  a  con- 
certed effort  for  better  health.  It  is  not  to  be  expected  that 
the  Foundation  will  undertake  this  work  for  every  commun- 
ity. It  can  merely  demonstrate  methods  of  control,  and  the 
various  communities  may  accept  them  or  reject  them  as  they 
see  fit. 

The  American  Bed  Cross,  the  American  Child  Hygiene 
Association,  the  National  Tuberculosis  Association  and  many 
other  public  and  semi-public  organizations  are  working  along 
the  same  general  lines  as  the  Bockefeller  Foundation.  Some 
are  endowed  and  others  secure  their  funds  largely  through 


148       THE  COMMUNITY  HEALTH  PBOBLEM 

public  subscriptions.  They  should  all  be  looked  upon  as 
merely  auxiliary  organizations  and  should  in  no  case  replace 
public  health  activities  or  community  health  effort. 

The  American  Bed  Cross  as  part  of  its  peace-time  program, 
places  special  emphasis  upon  community  service  for  better 
health.  This  work  is  to  be  in  addition  to  the  already  eBtaI>* 
lished  activities  for  military  and  civilian  relief  and  is  to 
supplement  them  in  local  communities.  For  this  purpose  a 
new  department  has  been  organized,  the  Department  of  Health 
Service,  the  purpose  of  which  is  to  give  national  and  com- 
munity service  for  the  development  of  better  health.  **The 
opportunity  and  responsibility  have  been  brought  home  to  our 
chapters,"  says  the  Bed  Cross  Bulletin,*  ''by  the  widespread 
demands  for  help  along  health  lines  in  the  several  com- 
munities, as  well  as  by  the  national  conviction  that  we  face 
an  emergency  and  continuing  disaster  in  the  health  field  not 
less  alarming  than  the  emergency  of  war." 

The  health  service,  briefly,  includes:  (1)  Service  for  the 
extension  of  public  education  through  health  lectures,  posters, 
pamphlets  and  books,  together  with  the  collection  and  dis- 
tribution of  health  information  and  statistics;  (!^)  The 
establishment  of  health  centers  in  the  effort  to  coordinate 
official  and  other  health  agenda  serving  the  community; 
(3)  The  promotion  of  community  health  studies;  (4)  The 
organization  and  promotion  of  classes  in  first  aid  and  life 
saving,  thereby  tending  to  prevent  accidental  injury  and 
death. 

The  Bed  Cross  nursing  service  has  already  been  referred  to. 
The  activities  of  the  Department  of  Nursing  have  been  out- 
lined as  follows: — ^"(1)  Providing  a  public  health  nurse  for 
your  community,  if  you  have  none;  (2)  Conducting  dass  in 
home  care  of  the  sick;  (3)  Abating  in  organizing  and  super- 
vising any  health  activity  pertaining  to  nutrition." 

The  peace-time  health  program  of  the  Bed  Croes,  as 
outlined  above,  is  too  recent  in  origin  to  permit  of  con« 
elusions  as  to  its  efficacy  for  community  health  betterment 

*Jaiuuj7  5,  192a 


^^ 


ENDOWED  HEALTH  DEMONSTRATIONS     149 

but,  if  we  may  judge  from  past  performances,  the  American 
Red  Cross  may  be  expected  to  accomplish  appreciable  results 
and  to  play  an  important  part  in  the  movement  for  better 
health. 

However,  it  is  to  be  remembered  that  the  Red  Cross  is 
not  to  be  considered  as  a  sort  of  enlarged  health  department 
which  undertakes  to  solve  the  health  problems  of  the  world 
but  rather  that  the  health  movement  is  simply  an  attempt 
to  make  the  resources  of  experience  and  information  of  this 
vast  organization  available  to  each  and  every  community 
where  the  health  is  appreciated  and  where  serious  efforts  are 
being  made  for  its  ultimate  improvement. 

The  Russell  Sage  Foundation  is  an  endowment  fund  which 
is  devoted  in  part  to  the  development  of  public  health.  The 
purpose  of  the  Sage  Foundation  is  "the  improvement  of  so- 
cial and  living  conditions  in  the  United  States  of  America." 
The  endowment  consists  of  $10,000,000  donated  by  Mrs.  Rus- 
sell Sage.  It  is  apparently  the  policy  of  the  trustees  of  the 
fund  to  devote  the  income  largely  to  research,  but  they  have 
in  several  instances  taken  an  active  part  in  health  movements 
among  which  may  be  mentioned  tiie  anti-tuberculosis  cam- 
paign, medical  inspection  in  schools,  and  the  management  of 
childien  in  institutions.  A  publication  department  is  main- 
tained  and  many  books  and  pamphlets  on  subjects  dealing 
with  health  and  welfare  are  published. 

The  N'ew  York  Department  of  Health  has  a  slogan  to  the 
effect  that  within  limits  health  is  purchasable.  Certainly  the 
studies  and  experiences  of  these  organizations  would  seem  to 
justify  this  statement  and  to  diow  that,  in  some  cases  at 
least,  it  may  be  purchased  at  a  comparatively  low  price. 
However,  in  spite  of  the  evidence  at  hand,  it  has  taken  many 
years  and  much  labor  to  induce  legislatures  to  adopt  a  broad 
conception  of  the  health  problem  and  to  appropriate  funds  for 
health  purposes  in  amounts  sufficient  to  permit  the  public 
authorities  to  wage  m(»t  effectively  the  fight  against  prevent- 
able disease. 


REFERENCES 

A  PARTIAL  LIST  OF  REGENT  PUBUGATIONS 

Amab.  Julbs:    Physidlosjr  of  Industrial  Organisation  and  the  B»- 

Employroent  of  the  Dialled,  1919. 
Ambbican  Rso  Cross:    Health  Centers,   A   Field  for   Red   Croas 

Acitivity.    Booklet,  Washington.  Sept.,  1919. 
Andkbas,  J.  Mace:    Health  Education  in  Public  Schools,  1919. 
Atbes,  Mat;  Wxluaus,  Jebsb  F.  ;  and  Wood,  Thouas  D.  :    Healthful 

Schools,  1918. 
Babton,  Gbobob  Edwabd:    Teaching  the  Sick.    A  Manual  of  Oo- 

cupational  Therapy  and  Re-£ducation,  1919. 
BBS1^  H  ABBT :    The  Bhnd,  Their  Condition  and  the  Woric  Bmng  Done 

for  Them  in  the  United  States,  1919. 
BiBBOP,  RoBBBT  H.:    Health  Center  in  a  Large  City,  American 

Journal  of  Nursing,  July,  1917. 
Bbainbbd.  Annid  M.:    Organisation  of  Public  Health  Nursing,  1919. 
Bbbnd,  W.  a.:    Health  and  the  State,  1918. 
Bboadhubst,  Jban:    Home  and  Community  Hygiene.    A  Text-book 

<d  Personal  and  Public  Health.  1918. 
Btznoton,  M  aboabbt  F.  :    What  Social  Wooers  Should  Enow  About 

Their  Own  Communities,  Russell  Sage  Foundation,  1918. 
Cabot,  Richabo  C:    Social  Work,  Essays  on  the  Meeting  Ground 

of  Doctor  and  Sodal  Worker,  1919. 
Cakus,  Jban:    Physical  and  Occupational  Re-Education  of  Maimed. 

1919. 
Catlin,  Luct  Cabublza:    The  Hospital  as  a  Social  Agency  in  the 

Community,  1918. 
Dawson,  Bebtband:    The  Nation's  Welfare.    The  Future  of  tifs 

Medical  Profession  (Carendish  Lectures),  1918. 
DaviNB,  Edwabd  T.:    Disabled  Soldiers  and  Sailors  Pensiona  and 

Training,  1919. 
Dublin,  Louis  I. :    Mortality  Statistics  of  Insured  Waea  Earners  and 

Their  Families.    Experience  of  the  Metropolitan  Life  Insurance 

Company,  Industrial  Department,  1911-16. 
EvBBBTT,  Rat  H.  :    The  cost  of  Vener»u  Disease  to  Indxistry,  Jour,  of 

Industrial  Bjf^eaxe,  September,  1920. 
FABiBa,  John  Culbbbt:    The  Eoonomio  Consequences  of  Phyacal 

Disability,  Red  Cross  Institute  for  Crippled  and  Disabled  Men, 

New  York,  1918. 
Fbaminqbam  Communitt  Hbalth  AND  TuBBBCULoeis  Dbmonbtba- 

tionb:    Monographs,  Community  Health  Station,  Framingham, 

Mass.,  1918-1919. 
QoZiEB,  GBOBoa  W.:    Rochester  Bureaa  of  Health  C<»8uItation, 

Public  Health  Journal.  July,  1917. 
Hall,  Hbbbbbt  J.:    Bedside  and  Wheel-Chair  Occupaticms,  Red 

Croas  Institute  for  Crippled  and  Disabled  Men,  New  York,  1919. 


-^ 


REFEEENCES 

Habris,  Gabbabd;  «nd  BnajKos,  Frank:    The  Redemption  of  tbe 

Disabled.    A  Studv  of  Programs  ci  Rehabilitation  for  the  Disabled 

of  War  and  of  Inaustty,  1919. 
EomcAN,  FaaoaBiCK  L.:    Industrial  Accidents  in  the  United  States 

and  Their  Relative  Frequency  in  DiGFeient  Oocupatioos,  Prudential 

Life  Insurance  Company,  1918. 
:    A  Plan  for  More  Effective  Federal  and  State  Health 

Administration,  Prudential  Life  Insurance  Company,  1919. 
HoQAN,  F.  B.:    Schools  for  Health  Centers,  Survey,  Dec.  14, 1918. 
Lbaqub  of  Red  Cboss  SociKTisa  BxTUiSTiir:     The  PuUio  Health 

Pn^ram,  July.  1920. 
LiFprrr,  Loxtiba  C.:    Personal  Hygiene  and  Home  Nursing,  1919. 
MacKunzix,  Jamxb:    The  Future  of  Medicine,  1919. 
McDnj.,  John  R.:    Lessons  from  the  Enemy.    How  Germany  Cares 

for  Her  War  Disabled,  1918. 
McMttbtbeb,  DonoLAS  C:    The  Disabled  Soldier,  1919. 
:    The  Evolution  of  National  Systems  of  Vooational  Re- 
habilitation.   Issued  by  Federal  Board,  1918. 
Mm>iCAi<  RsdJiABCH  Coioutteb:    National  Health  Insurance,  Third 

Annual  Report,  London,  1917. 
:    An  Inquiry  into  the  Prevalence  and  Etiology  of  Tuberculo- 
sis Among  Industrial  Workers,  London,  1919. 
Mktxb,  Ebnst  C:    Hospital  Service  in  Rural  Communities,  Journal 

American  Medical  AiBociation,  April  19  and  26,  May  3, 10,  and  17, 

1919. 
Mock,  Habst  E.  :    Industrial  Medicine  and  Surgery,  1919. 
National  Indubtbiajl  Contbrbncs   Boabd:    Hours  of  Work  as 

Related  to  Output  and  Health  of  Workers,  Boston,  1919. 
National  Social  tlNTr  Obganuatzon:    Bulletins  1  to  5,  New  York, 

1919. 
New  York  Statb  Dbpaktment  of  Hvai/fb  :    Health  Centers,  Monthly 

Bulletin.  Aug.  and  Dec.,  1918;  Feb.  and  June.  1919. 
Pattison,  H.  a.:    Productive  Vocational  Workshops  for  Rehabilita- 
tion of  the  Tuberculous  and  Other  Dis^led.  Soldiers,  Federal 

Board  for  Vocational  Training,  1919. 
PlSTEBSON,  Ebwin  A. :    The  Program  of  the  Red  CrosB,  Journal  Amer. 

Med.  Assn.,  Aug.  28. 1920. 
Ross,  Elizabxth:    JBealth  Activities  at  a  Civio  Center  in  a  Small 

Community,  American  Journal  of  Nursing,  August,  1917. 
ScHAFER,  A.  C. :    Public  Health  Center  Field  Work,  New  York  State 

Journal  of  M«iicine,  April,  1917. 
Stokbs,  John  H.:    Today's  World  Problem  in  Disease  Prevention.  A 

Non-Technical  Discussion  of  Syphilis  and  Gonorrhoea,  U.  S. 

Publio  Health  Service,  1919. 
Wrioht,  FLOBBNca  Swift:    Industrial  Nursing,  1919. 
Government  Documents 

Reports  and  special  articles  bearing  on  community  health  are 
publidied  by  the  Children's  Bureau  and  the  Labor  Statistics  Bxireau  of 
the  Department  of  Labor;  by  the  Publio  Health  Service  of  the  Treasury 
Department:  and  by  the  Bureau  of  Education,  Department  of  the 
Interior.  The  Federal  Board  of  Vocational  Education  publishes  a 
monthly  magazine  and  a  series  of  bulletins  on  rehabilitation. 


INDEX 

Accidents,  Prevention  of , 56, 63 

Accidents,  Indnstrial,  and  Liability  Laws 67 

Adnlts,  Sick  Rates 9 

Administration  of  Compensation  Laws 71 

Alameda  Gonnty  Health  Center 104 

American  Association  of  Labor  Legislation 76 

American  Bed  Cross  Health  Centers   99 

American  Bed  Cross,  Peace  Time  Program  148 

Appropriations  for  Pnblic  Health 35 

Bedside  Nursing    42 

Benefits,  of  Compensation  Acts  70 

Benefits,  of  Health  Insurance  82 

Board  of  Health,  Appropriations  for  35 

Board  of  Health,  Local 33 

Board  of  Health,  North  Carolina  36 

Board,  Litemational  Health 143 

Bureau  of  Child  Hygiene 8 

Campaign  for  Better  Health 54 

Care  of  Employees 89 

Case  Histories,  Disabled  Soldiers   136 

Cash  Benefits  of  Compensation  Laws 70 

Center,  Maternity 60 

Centers,  Industrial  Health  103 

Centers,  Health 99 

Centers,  Bed  Cross  99 

Children,  Examination  of  School 8 

Church  Control  of  JJ'ursing  48 

Civilian  Cripples,  Rehabilitation  of 137 

Colleges  Teaching  Public  Health  Nursing 41 

Community  Health,  The  Private  Physician  and 23 

Communi^  Nursing    48 

Compensation  Insurance,  Workmen's 67 

Compensation  Laws,  Effect  on  Use  of  Safety  Devices.  74 


INDEX 

CompnlBOzy  Health  Insorance  75 

Crippled  and  Disabled  Men,  Institute  for 60 

Crippled  fin^loyees  of  Ford  Motor  Company 60 

Cripple8>  Civilian,  Behabilitation  of 137 

Cripples,  Industrial   129 

Deatn  Benefits  Under  Compensation  Laws 70 

Defective  Children  in  New  York  State 8 

Demonstration,  Framingham  Health   10 

Demonstration,  Health   54 

Departments,  Health    30 

Departments,  Local  Health   34 

Departments,  State  Hesdth 33 

Disabled,  Eehabilitation  of  61, 128 

Disabled  Soldiers,  Case  Histories 136 

Disabled  Soldiers,  Rehabilitation  of  61 

Disability  As  Cause  of  Mental  Depression 128 

Disabled  in  Selective  Draft 4 

Disability  Insurance  for  Employees 91 

Disability,  Percentage  in  Community 12 

Disabiliiy,  Percentage  in  Draft  Examinations 6 

Disability  Table  of  Defects  Found  in  Draft 5 

Disease,  Hookworm,  Methods  Used  Against 143 

Disease,  Prevention  of 56 

Disease,  Treatment  of  58 

Diseases,  Cause  of   3 

Diseases,  Industrial  and  Workmen's  Compensation 72 

Draft  Army,  Percentage  of  Defects  in 6 

Draft,  Disability  Discovered  by 4 

Draft,  Table,  Disability  Discovered  by 5 

Dumferline  Scale   8 

Dutchess  County  Survey  27 

Education  Influenced  by  Rockefeller  Foundation 142 

Employees,  Medical  Care  of 89 

Employments  Included  Under  Workmen's  Compensation  71 

Endowed  Health  Demonstrations 139 

Examination  of  School  Children 7 

Expenditure  for  Sickness   17 

Expenditures  of  Local  Health  Departments 84 

Expenditures,  Yearly  for  Sickness 18 

Experiment,  Social  Unit 108 

Federal  Board  of  yocational  Training 131 


THE  COMMIINITY  HEALTH  PROBLEM 

Federal  Department  of  Health 93 

Fees  for  Public  Health  Nursing 49 

Pord  Motor  Company  and  Disabled  Employees 60 

Framingham,  Health  Demonstration  in 10 

French  Campaign  Against  Tuberculosis 140 

Government,  Expenditures  for  Health 34' 

Government,  Federal,  and  Disabled  Soldier 131 

Handicap,  in  Vocational  Training 134 

Health  Appropriation  Per  Capita  35 

Health  Board,  International  143 

Health  Campaign  in  North  Carolina  141 

Health  Center,  Definition  of 101 

Health  Center  of  Alameda  County 104 

Health  Centers   99 

Health  Centers,  Aims  of 100 

Health  Centers  and  Hospitals  104 

Health  Centers,  Industrial   87 

Health  Centers,  Red  Cross  Program 106 

Health  Centers,  Sage-Machold  Bill  for  105 

Health  Centers,  Ten  Reasons  for 105 

Health  Conditions  in  U.  S.  Army : 11 

Health  Demonstration   54 

Health  Demonstration  in  Framingham 10 

Health  Demonstrations,  Endowed   139 

Bealth  Departments 30 

Health  Departments,  Local   34 

Health  Departments,  State    33 

Health  Insurance    21 

Health  Insurance  and  the  Public  81 

Health  Insurance,  Cash  Benefits  in  82 

Health  Insurance,  Compulsory 75 

Health  Insurance  for  Industrial  "Workers 90 

Health  Insurance,  Growth  of 75 

Health  Insurance,  Meaning  of    76 

Health  Insurance,  Medical  Clare  in 79 

Health  Insurance  Premiums  78 

Health  Program  of  American  Red  Cross 148 

Health  Service  in  Social  Unit  Experiment 112 

Health  Study  by  Metropolitan  Life  Insurance  Co 9 

Henry  Street  Settlement 50 

Home  Care   65 


INDEX 

Hookworm  Djisease  Combated  bj  Bockefeller  Fonnda- 

tion 143 

Hookworm  Survej  in  Jamaica 144 

Hospital  Care  65 

Hospitals  and  Health  Centers  104 

Hygiene,  Social 122 

Industrial  Cripples 129 

Industrial  Diseases  Under  Compensation  Laws 72 

Industrial  Health  Centers   87, 102 

Industrial  Hygiene  in  Public  Health  Service  Program  31 

Industrial  Medicine    84 

Industrial  Medicine  and  Home  Care 65 

Industrial  Medicine,  Expenses  of 86 

Industrial  Medicine,  Methods    85 

Industrial  Nursing ■.  45 

Industrial  Physician,  Work  of 103 

Industry,  Physical  Examination  in 88 

Infancy,  Disease  of,  in  Public  Health  Service  Program  82 

Infant  Welfare   63 

Injury,  Treatment  of 68 

Insurance  Carriers  for  Proposed  Health  Insurance...  77 
Insurance  Carriers  for  Workmen's  Compensation  In- 
surance  ^ 72 

Insurance,  Compulsory  Health 75 

Insurance  for  Industrial  Workers 90 

Insurance,   Health   21, 72 

Insurance  Nursing  61 

Insurance,  Workmen's  Compensation  67 

Institute  for  Crippled  and  Disabled  Men 60, 130 

International  Health  Board  143 

Jamaica,  Hookworm  Survey  in 144 

Kensington  Survey 17 

Liabili^  Laws  and  Industrial  Accidents 67 

Life  Insurance  Nursing 61 

Loss  of  Wages  Due  to  Sickness 17 

Major  Handicap  in  Vocational  Training, 134 

Major  His  in  Framingham  Survey 11 

Malaria,  Arkansas  Experiment  145 

Malaria,  Control  of 5145 

Malaria,  Expenses  for  Extermination  of jl9 

Mal-nutrition  in  School  Children 8 


THE  COMMUNITY  HEALTH  PEOBLEM 

Mal-nutrition,  Public  Health  Service  Program 32 

Maternity  Care  63 

Matemify  Center   50 

Medical  Attention  During  Vocational  Training 135 

Medical  Attention  Under  Compensation  Laws 69 

Medical  Care  in  Social  Unit  Experiment Ill 

Medical  Care,  Failure  to  Secure 27 

Medical  Care  of  Employees  89 

Medicine,  Industrial 84 

Medicine,  State 92 

Mental  Depression  Caused  by  Disability 128 

Metropolitan  Life  Insurance  Co.,  Sickness  Surveys  by..  9,26 

Metropolitan  Life  Insurance  Nursing   51 

Minor  Handicap  in  Vocational  Training 134 

Minor  Ills,  Table  of 11 

Mohawk-Brighton  Experiment,  Evaluation  of 109 

National  Organization  for  Public  Health  Nursing. ...  39 

National  Social  Unit  Organization  108 

Negligible  Handicap  in  Vocational  Training 134 

New  York  Cily,  Examination  of  School  Children....  9 
New  York  City,  Mal-nutrition  in  School  Children ...  8 
New  York  State,  Physical  Condition  of  School  Chil- 
dren   8 

North  Carolina  Health  Campaign 141 

Nursing,  Community   48 

Nursing  Industrial    45 

Nursing  in  Public  Health  Work 62 

Nursing,  Insurance 61 

Nursing,  Public  Health 38 

Nursing,  School    46 

Nursing  Service  for  Industrial  Workers 89 

Organization  for  Public  Healii.  Nursing 39 

Organization,  Social  Unit 100 

Percentage  of  Defects  in  Draft  Army 6 

Physical  Examination  in  Industry 88 

Physician,  Private  in  Community  Healtii  Work 23 

Physician,  Relation  of  Visiting  Nurse  and 42 

Physicians  and  Vocational  Training   132 

Physicians,  Attitude  of  Toward  Health  Insurance 79 

Physician's  Calls  Influenced  by  Malarial  Control 146 

Physicians,  XTodfir  State  Medicine 97 


INDEX 

Poverby  and  Sickness 15 

Premiums  of  Health  Insurance 78 

Pre-natal  Care   63 

Prevention  of  Accidents    56 

Prevention  of  Disease    56 

Private  Practice  and  State  Medicine 93 

Public  Attitude  Toward  Health  Insurance 81 

Public  Health,  A  Function  of  the  State 81 

Public  Health  Nursing   38 

Public  Health  Nursing  and  Bed  Gross 40 

Public  Health  Nursing,  Fees  for  49 

Public  Health  Nursing,  Growth  of 39 

Public  Health  Nursing  in  Social  Unit  110 

Public  Health  Nursing  for  Tuberculosis 44 

Public  Health  Nursing,  National  Organization  for...  39 

Public  Health  Nursing,  Specialization  in  43 

Public  Health  Nursing,  Training  for 40 

Public  Health  Service  31 

Public  Health  Service  Campaign  Against  Sex  Diseases  134 

Public  Health  and  Visiting  Nursing  52 

Red  Cross  Health  Centers  99 

Bed  Cross  Program  for  Health  Centers 106 

Red  Cross  Public  Health  Nursing  40 

Rehabilitation  69 

Rehabilitation  of  Civilian  Cripples  137 

Rehabilitation  of  Disabled  Soldiers 61, 128 

Rehabilitation,  Origin  of 130 

Rockefeller  Foundation 139 

Rockefeller  Foundation,  Malarial  Expenses  in  Arkansas  19 

Rural  Hygiene  in  Public  Health  Service  ProOTam 31 

Russell  Sage  Foundation,  Influence  on  Public  Health. .  149 

,  Safe^  Devices  Increased  by  Compensation  Laws 74 

Sage-Machold  Bill  for  Health  Centers 105 

Scale,  Dumferline  . .' 8 

School  Children,  Examinations  of  7 

School  Children,  Physical    Condition    in   New   York 

State  8 

School  Nursing > 46 

Service,  Health 9 

Sewage  Disposal,  Public  Health  Service  Program 32 

Sex  Diseases,  Control  of 123 


DATE  DUE 

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